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Home My WebLink About20192198.tiffean-frad- ID 450 I g PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: July 13, 2021 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Agreement Amendment with IDEA Forum, Inc. 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 IDEA Forum, Inc. The Department entered into a Child Protection Agreement for Services with IDEA Forum, Inc., identified as Tyler ID 2019-2198, on June 12, 2019. The Agreement was Amended on May 13, 2020 to extend the term date to May 31, 2021 and amended again on April 19, 2021 to extend the term date to May 31, 2022. The Agreement is now being amended to update the Scope of Services and Rate schedule with the changes noted below. Scope of Services Changes: • Updated the Contractor's service access locations: 0 2370 E. Alameda Avenue, Suite 8, Denver CO 80223 0 14311 East 4'h -Avenue; AMrera, CO -80011 630 Peoria St, Aurora C() 80011 Rate Schedule Changes: Domestic Violence Intervention Rate Unity Type Service Name $1275.00 Episode Anger Management Evaluation $345.00 Episode Domestic Violence Group — two (2) hours per episode $17580.00 Episode Domestic Violence Intake Evaluation $75.00 Hour Team Decision Making (TDM1 Meeting. Family T Medina (FTM). Staffing Mental Health Services Rate Unity Type Service Name $3845.00 Episode Adolescent Group Therapy — two (2) hours per episode $45.00 Hour Adolescent Individual Therapy $86100.00 Hour Eye Movement Desensitization and Reprocessing (EDMR) Therapy $675.00 Hour Family Therapy $675.00 Hour Individual Therapy $345.00 Episode Standard Group Therapy — two (2) hours per episode Pass -Around Memocandum; July 13, 2021— ID 5018 cc: 0A-0-18-0 7,„2i- / Page l a0 /1- a X43 7 -as -020a1 PRIVILEGED AND CONFIDENTIAL $75.00 Hour Team Decision Making (TDM) Meeting, Familv Team MeetiAg (FTM). Staffing Monitored Sobriety Services Rate Unity Type Service Name $45.100.00 Test Hair Test $25.00 Test 1395 (Methamphetamine/Amphetamine, Barbituate. Benxo, CocaineSpiates. Prpogyphene, THC. Ethyl Glucuronide, Methadone. Buorenorohine/Suboxone. Tramadol. Fentanvl Substance Abuse Treatment Rate Unity Type Service Name $ IL38.00 Episode Substance Abuse Evaluation $360.00 Episode Substance Abuse Intake Assessment $75.00 Hour Team Decision Making (TDM) Meeting, Familv Team Meeting (FTM), Staffing I do not recommend a Work Session. I recommend approval of this Amendment and authorize the Chair to sign. Approve Recommendation Perry L. Buck Mike Freeman Scott K. James, Pro-Tem Steve Moreno, Chair Lori Saine Schedule Work Session Other/Comments: Pass -Around Memorandum; July 13, 2021— ID 5018 Page 2 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND IDEA FORUM, INC. This Agreement Amendment, made and entered intoC. /SIday of 2021 by and between the Board of Weld County Commissioners, on behalf of the Weld County par nt of Human Services, hereinafter referred to as the "Department", and IDEA Forum, Inc., here' fter re erred to as the "Contractor". WHEREAS the parties entered into an Agreement for Domestic Violence Intervention, Mental Health Services, Monitored Sobriety Services, and Substance Abuse Treatment, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-2198, approved on June 12, 2019. 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, 2020. • The Original Agreement was amended on: May 13, 2020 to extend the term date through May 31, 2021. April 19, 2021 to extend the term date through May 31, 2022. The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2019-2198. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Exhibit C, Scope of Services, is hereby amended as attached. 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. ��II COUNTY: ATTEST: V�4N v•�� BOARD OF COUNTY COMMISSIONERS Weld By: Clerk to the Bo WELD COUNTY, COLORADO Deputy Cle 2370 West Alameda Avenue, Suite 8 Denver, Colorado 80223 ve Moreno, Chair NTRACTOR: IDEA Forum, Inc. By: Date: fiIazela Baia JUL 2 12021 Marcela Paiz, Owner Jul 7, 2021 oZoic_ ov / ir EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide Domestic Violence Intervention, Mental Health Services, Monitored Sobriety Services, and Substance Abuse Treatment, as referred by the Department. 2. Contractor will utilize the following in the delivery of service: a. DV Evaluation and Treatment i. Contractor will conduct service per DVOMB standards, and services will be provided by a DVOMB provider. b. Substance Use Disorder Evaluation and Treatment c. DUI Education and Treatment d. Anger Management e. Adult Responsibility f. Victim Empathy g. Parenting h. Life Skills 3. Capacity for Services: Intensive Outpatient (IOP) — 9+ hours per week. 4. Goals of Service: To identify, and address risks and need of the client and increase skills for relationships and parenting. 5. Outcomes of Services: Reduction or elimination of harm to self or others, recovery work in victim empathy, accountability in safe and secure relationships. 6. Target Population: a. Ages 14 to 99 years old b. Male and female (treatment is gender specific) c. LGBTQ services offered 7. Language: English and Spanish. All languages accepted with translator. 8. Service Access: a. In-office/in-person b. 2370 E. Alameda Avenue, Suite 8, Denver CO 80223 c. 630 Peoria St. Aurora CO 80011 d. 83 North 4th Avenue, Brighton, CO 80601 e. 9051 Washington Street, Thornton, CO 80229 Terms 1. Contractor will respond to the Quality Assurance Team LHS-CWOualitvAssurance(aweldgov.com within three (3) business days regarding the ability to accept the received referral. 2. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Quality Assurance Team HS- CWOualitvAssurance(aweldgov.com. 1 3. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understands that the Department will not reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team HS-CWQualitvAssurance(a,weldgov.com. 4. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Quality Assurance Team HS-CWQualitvAssurancena,weldgov.com immediately via email, to discuss service continuation. 5. Contractor will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 6. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 7. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 8. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Quality Assurance Team. Any changes to visitation referrals will be approved by the caseworker, their supervisor, or the Family Support and Visitation Center. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 9. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Bid Meetings, Professional Staffmgs, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Quality Assurance Team, and the Contractor obtains the Facilitator's signature on the Client Verification Form (if in person) at the time of the meeting and participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the Client Verification Form. Staffmgs and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone, if approved by the Department. 10. Contractor will notify the Quality Assurance Team HS-CWQualitvAssurance(u,weldgov.com of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information 2 b. Education level/degree (if applicable) c. Licenstre/credentials (if applicable) d. Department ofRegulatory 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. 3 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, 2020. 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 Domestic Violence Intervention Rate Unity Type Service Name $175.00 Episode Anger Management Evaluation $45.00 Episode Domestic Violence Group — two (2) hours per episode $175.00 Episode Domestic Violence Intake Evaluation $75.00 Hour Team Decision Making (TDM) Meeting, Family Team Meeting (FTM), Staffing Mental Health Services Rate Unity Type Service Name $45.00 Episode Adolescent Group Therapy — two (2) hours per episode $45.00 Hour Adolescent Individual Therapy $100.00 Hour Eye Movement Desensitization and Reprocessing (EDMR) Therapy $75.00 Hour Family Therapy $75.00 Hour Individual Therapy $45.00 Episode Standard Group Therapy — two (2) hours per episode $75.00 Hour Team Decision Making (TDM) Meeting, Family Team Meeting (FTM), Staffmg Monitored Sobriety Services Rate Unity Type Service Name $17.00 Test 7 Panel Urinalysis $10.00 Test Breathalyzer $100.00 Test Hair Test $165.00 Test Steroid Urinalysis $25.00 Test Swab Test $25.00 Test 1395 (Methamphetamine/Amphetamine, Barbituate, Benzo, Cocaine, Opiates, Prpoxyphene, THC, Ethyl Glucuronide, Methadone, Buprenorphine/Suboxone, Tramadol, Fentanyl) Substance Abuse Treatment Rate Unity Type Service Name $175.00 Episode Substance Abuse Evaluation $60.00 Episode Substance Abuse Intake Assessment $75.00 Hour Team Decision Making (TDM) Meeting, Family Team Meeting (FTM), Staffing 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. New Contract Request Entity Name* IDEA FORUM, INC Entity ID* 00027225 Contract Name* IDEA FORUM, INC (,AGREEMENT AMENDMENT) Contract Status CTE REVIEW Contract ID 5018 Contract Lead* APEGG Contract Lead Email apegggrvveldgov. corn; cobbx xl kfoweldgov. corn Contract Description CONSENT - AGREEMENT AMENDMENT, NEW SCOPE OF SERVICES AND RATE SCHEDULE Contract Description 2 PA IS BEING SENT THROUGH THE NORMAL PROCESS. ETA TO CTE. 7/15=21. Contract Type AMENDMENT Amount* S0.00 Renewable* NO Automatic Renewal n HUMAN SERVICES nt Email CM - H uman Se rvice s(Aiue Idgov. co m Department Head Email CM-HumanServices- DecAHead:gweldgov.com ['n++nty Attorney GENERAL COUNTY A I I ORNEY EMAIL Comity Attorney Email CM- COU NTYA I I O RN EY @WELDG OV.COM If this is a renenter previous Contract ID If this is part of a Mt SA enter MSA Contract ID Requested BOCCC Date* 07/21/2021 Parent Contract ID 20192198 Requires Board YES Department Project # Due Date 07/17/2021 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? Note= the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* 0401 2022 Renewal Date Termination Notice Period Contact Information Contact Name Contact Type PlirthaSin Pu chas ng Approver CONSENT Approv PraceSS Department Head JAMIE ULRICH DH Approved Date 07/12/2021 Final Approval MCC Approved BOCC Signed Date ROCC Agenda Date 07121;2021 Originator APEGG Committed Delivery Date Contact Email Finance Approver CONSENT Expiration Date* 05;31!2022 e 1 Contact Phone 2 Purchasing Approved Date 07:12/2021 Legal Counsel CONSENT Finance Approved Date Legal Counsel Approved Date 07/12i2021 07/12,/2021 Tyler Ref # AG 072121 0174-i9-02/ PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: March 30, 2021 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Protection Agreement Amendments for 2019- 20 CoreJNon-Core Contracted Services 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 2019- 20 Core/Non-Core Contracted Services. The Department entered into Agreements with various Child Welfare service providers through the 2019-2020 Request for Proposal (RFP), Bid Number: B1900025, identified as Tyler ID 2019-0707. 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 34 providers reflected in the attached list. Agreements will be renewed for the third and final year for the period of June 1, 2021 through May 31, 2022. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Upon Board approval of this pass -around, signed Agreement Amendments will be obtained from providers and submitted to the Board for approval and Chair signature. I do not recommend a Work Session. I recommend approval of these Agreement Amendments. Approve Recommendation Perry L. Buck Mike Freeman Scott K. James, Pro-Tem Steve Moreno, Chair Lori Saine Schedule Work Session Other/Comments: Pass -Around Memorandum; March 30, 2021— CMS ID — Various elsA(:) ,f-qg,02-/ Page 1 0,24rig- g- 02/9 //IedD 90 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND IDEA FORUH/"M, INC. This Agreement Amendment, made and entered into eday of of Weld County Commissioners, on behalf of the Weld County Department of Hum "Department", and IDEA Forum, Inc., hereinafter referred to as the "Contractor". 2021 by and between the Board Services, hereinafter referred to as the WHEREAS the parties entered into an Agreement for Domestic Violence Intervention, Mental Health Services, Monitored Sobriety Services, and Substance Abuse Treatment, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-2198, approved on June 12, 2019. 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, 2020. • The Original Agreement was amended on: May 13, 2020 to extend the term date through May 31, 2021. The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2019-2198. • 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, 2021 through May 31, 2022. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTES • WAalliet) G►• Kde40; eik BOARD OF COUNTY COMMISSIONERS Weld ' ou ty Clerk to the WELD COUNTY, COLORADO By: Deputy Cler.%to the Bear Moreno, Chair RACTOR: Forum, Inc. 70 West Alameda Avenue, Suite 8 Denver, Colorado 80223 APR 1 9 2021 By: Date: /Wanda RI/ Marcela Paiz (Apr 11, 202117:08 MDT) Marcela Paiz, Owner Apr 11, 2021 020/9 - ?8' Contract Form IGA New Contract Request Entity Information Entity Name* IDEA FORUM, INC Entity ID* 8O0027225 Contract Name* IDEA FORUM, INC. (AGREEMENT AMENDMENT) Contract Status CTB REVIEW Contract Description* BID IflB1900025. TERM: 6;1 '21-5 31 22. Contract Description 2 CONSENT. PA WAS SENT TO Contract Type AMENDMENT Amount* S0.00 Renewable* NO Automatic Renewal t CTB ON 3 ' 31 , 2. Department HUMAN SERVICES Department Email CM - H umanServices,Pweldgov.co m Department Head Email CM-HumanServices- DeptHead weldgov,com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEYf WELDG OV.COM ❑ New Entity? Contract ID 4652 Contract Lead* APEGG Contract Lead Email apeggglweldgov.com:cobbx xlkgweldgov.com Requested BOCC Agenda Date* 05:26/2021 Parent Contract ID 20192198 Requires Board Approval YES Department Project It Due Date 05'22,2021 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? tf this is a renewal enter previous Contract ID If this is part of a PASA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* 04,01;2022 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 04;`13,'2021 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 04;19.'2021 Originator APEGG Contact Type Committed Delivery Date Contact Email Finance Approver CONSENT Expiration Date* 05131/2022 Contact Phone i Purchasing Approved Date 04;'1312021 Finance Approved Date 04;13/2021 Tyler Ref # AG 041921 Legal Counsel CONSENT Contact Phone 2 Legal Counsel Approved Date 04'1312021 G0.1 hnOr.cj". .=•:r -4* 5603 PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: April 2, 2020 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Welfare 2020-21 Service Provider Agreement Amendments 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 Welfare 2020-21 Service Provider Agreement Amendments. The Department entered into agreements with various Child Welfare service providers through the 2019-20 Request for Proposal (RFP), identified as Tyler ID 2019-0707). These agreements were issued for a period of three years with the option to renew annually. The attached list reflects the providers, services and rates, including minor rate changes, the Department wishes to enter into for the period of June 1, 2020 through May 31, 2021. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Upon Board approval of this pass -around, signed agreement amendments will be obtained from providers and submitted to the Board for approval and Chair signature. I do not recommend a Work Session. I recommend approval of these Agreement Amendments. Mike Freeman, Chair Scott James Barbara Kirkmeyer Steve Moreno, Pro-Tem Kevin Ross Approve Recommendation Work Session Schedule w Other/Comments: Pass -Around Memorandum; April 2, 2020 — Not in CMS ®s fr3/2o O5 h3/20 Page 1 a.o/q- ,2118 1+Ro0470 VENDOR RENEWALS Vendor Program Area Service Name Family Therapy -Intake Funding Core _ Rate $ 59.00- Unit Type Hour - Individual Therapy Core $ 65.00 Hour Individual Therapy, In Home/Community Core $ 95.00 Hour Individual Therapy, In Home/Community-Intake Core $ 95.00 Hour Individual Therapy -Intake Gore $ 65.00 Hour Reload -Reboot Educational Learning Opportunities Affecting Direction Core $ 49.00 Hour Reload -Reboot Educational Learning Opportunities Affecting Direction, In Home/Community Based Core $ 71.00 Hour Reload -Reboot Educational Learning Opportunities Affecting Direction, In Home/Community Based - Intake Core $ 71.00 Hour Reload -Reboot Educational. Learning Opportunities Affecting Direction -Intake Core $ 49.00 Hour Staffing, FTM, TDM, etc. Core $ 30.00 Hour Telebehavioral Health Family Therapy Core $ 69:00 Hour Telebehavioral Health Family Therapy, In Home/Community Based Core $ 101.00 Hour Telebehavioral Health Family Therapy, In Home/Community Based -Intake Core $ 101.00 Hour Telebehavioral Health Family Therapy -Intake Core $ 69.00 Hour Telebehaviorat Health Individual Therapy Core $ 65.00 Hour Telebehavioral Health Individual Therapy, In Home/Community Based Core $ 95.00 Hour Telebehavioral Health Individual Therapy, In Home/Community Based -Intake Core $ 95:00 Hour Telebehavioral Health Individual Therapy -Intake Core $ 65.00 Hour Transportation -All Mental Health Services Core '. $ Osb Mile Truancy ASK (Advocate Success for Kids) Core $ 52.00 Hour Truancy ASK (Advocate Success for Kids), In Home/Community Based Core $ 76:00 Hour Truancy ASK (Advocate Success for Kids), In Home/Community Based -Intake Core $ 76.00 Hour Truancy ASK (Advocate Success for Kids) -Intake Core - $ 52.00 Hour Truancy ASK -Case Management Services Core $ 30.00 Hour Harmony Acres' Equestrian Center Mental Health Services Animal -Assisted Psychotherapy Core $ 85.00 Hour Heart -Centered Counseling Mental Health Services Medication Management Core $ 68.00 15 Min Medication Management, Assessment Core $ 158.00` Episode Medication Management, Discount g Core $ 100.00 30 min Mental Health Assessment Core $ 100.00 Hour Neuropsychological Evaluation Core $ 126.00 Hour No Show -Master's Level Session Core $ 85.00 Hour No Show-Ph.D. Level Session Core $ 93.00 Hour Outpatient Psychotherapy, Master's Level Core $ 89:00 Hour Outpatient Psychotherapy, Ph.D. Level Core $ 98.00 Hour IDEA Forum, Inc, Domestic Violence Intervention Anger Management Evaluation CV/ Block/Child Welfare Services $ 125.00 Episode Domestic Violence Group CW Block/Child Welfare Services $ 35.00 Episode Domestic Violence Intake Evaluation CW Block/Child Welfare Services $ 80.00 Episode WELD COUNTY DEPT. OF HUMAN SERVICES - CHILD WELFARE DIVISION 2020-21 SERVICE VENDORS (CORE/NON-CORE) BID NO.: 62000037 6 VENDOR RENEWALS Vendor Program Area Mental Health Services Service Name Adolescent Group Therapy Funding Core Rate $ 30.00 Unit Type Episode Adolescent individual Therapy Core ' $ 45#00 Noi r- EMDR Therapy Core $ 80.00 Hour Family Therapy Core $ 65.00 Hour Individual Therapy Core $ 65.00 Hour Standard Group Therapy Core $ 35.00 Episode Monitored Sobriety Services 7 Panel Urinalysis CW Block $ 17.00 Test Breathalyzer CW Black $ 10.00 Test Hair Test CW Block $ 75.00 Test Steroid Urinalysis CV/ Block $ 165.00 Test Swab Test CW Block $ 25.00 Test Substance Abuse Treatment Substance Abuse Evaluation Core S 150.00 Episode Substance Abuse Intake Assessment Core $ 50.00 Episode Inspired) Pathways Counseling Services Foster Care/Adoption Support Foster Parent/KinshipConsultation, In Office Core $ 150:00 Hour Foster Parent/Kinship Consultation, Out of Office Core $ 225.00 Hour Mileage Core $ 0.56 Hour Staffing, FTM, TDM, etc. Core $ 125.00 Hour Home Studies Extra Adult Beyond 2 Adults CW Block/Child Welfare Services $ 200.00 Episode Full Home Study, 2 Adults CW Block/Child Welfare Services $ 1,200.00 Episode Home Study Update CW Block/Child Welfare Services $ 800.00 Episode Mileage CW Block/Child Welfare Services $ 0.56 Mile Partial Home Study CW Block/Child Welfare Services $ 600.00 Episode Staffings or Other Pertinent Meetings CW Block/Child Welfare Services $ 130.00 Hour Life Skills Mileage Core $ 8.56 Mite Staffing, FTM, TDM, etc. Core $ 125.00 Hour Therapeutic Visitation/Parenting Skills, In Office Core $ 130.00 Hour Therapeutic Visitation/Parenting Skills, Out of Office Core $ 195.00 Hour Mental Health Services Family: Therapy, In Office Core $ 125;00 Hour Family Therapy, Out of Office Core $ 180.00 Hour individual Therapy, In Office Core S 125.00 Hour - Individual Therapy, Out of Office Core $ 180.00 Hour Mileage Core S 0.56 Mile Staffing, FTM, TDM, etc. Core $ 125.00 Hour Intervention, Inc. Monitored Sobriety Services 10 Drug Urinalysis -Panel 799 CW Block/Child Welfare Services $ 25,00 Test 7 Drug Urinalysis -Panel 22 CW Block/Child Welfare Services $ 14.00 Test 8 Drug Urinalysis with €tG-Panel280 CW Block/Child Welfare Services $ 15.00 Test Breath Test, Remote CW Block/Child Welfare Services $ 8.00 Day Confirmation Urine Test per Drug CW Block/Child Welfare Services $ 15.00 Drug Designer Stimulants/Synthetic Stimulants Confirmation per Drug CW Block/Child Welfare Services $ 20.00 Drug Designer Stimulants'/Synthetic Stimulants -Panel 3601 or 3701 CW Block/Child Welfare Services $ 40.00 Test EtG-Panel 2911 CW Block/Child Welfare Services $ 15.00 Test Lifelot FC 10 Plus Portable Breath Test CW Block/Child Welfare Services $ 3.00 Test Oral Fluid Confirmation per Drug CW Block/Child Welfare Services $ 25.00 Drug Oral Fluid -Panel 33 CW Block/Child Welfare Services S 20.00 Test SCRAM (Trans -dermal) CW Block/Child Welfare Services $ 8.50 Day WELD COUNTY DEPT. OF HUMAN SERVICES - CHILD WELFARE DIVISION 2020-21 SERVICE VENDORS (CORE/NON-CORE) BID NO.: 82000037 7 Ccsi 036o3 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND IDEA FORUM, INC. This Agreement Amendment, made and entered intoI 44.1 13 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 IDEA Forum, Inc., hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Domestic Violence Intervention, Mental Health Services, Monitored Sobriety Services, and Substance Abuse Treatment (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-2198, approved on June 12, 2019. 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, 2020. • 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 June 1, 2020 through May 31, 2021. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: 4.�U�/ �I• j'C.�w;ii Weld County Clerk to the Board By Clerk to the Board C.or.5r..,7C- Ag•evr.dat.' 0s7/ 3/aa COUNTY: BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO Mike Freeman, Chair MAY 13 2020 CONTRACTOR: IDEA Forum, Inc. 2370 West Alameda Avenue, Ste. 8 Denver, CO 80223 By: Date: Marcela Paiz (Apr 23, 2020) Marcia Paiz, Owner Apr 23, 2020 ec : H SO On @e,2e. 051 (31 a0 2o1q-tile t4.Ro©go Contract Form Entity Information Entity Name* IDEA FORUM, INC New Contract Request Contract Name* IDEA FORUM (AGREEMENT AMENDMENT) Contract Status CTB REVIEW Entity ID* @00027225 Contract ID 3603 Contract Lead* CULLINTA ❑ New Entity? Parent Corrtract ID Requires Board Approval YES Contract Lead Email Department Project # cullinta@co.weld.co.us Contract Description* CONSENT. BID NO. B2000037. BOCC APPROVAL: 04/15/20. CHILD PROTECTION AGREEMENT AMENDMENT. TERM: 06/01/20 THROUGH 05/31/21. Contract Description 2 Contract Type* AGREEMENT Amourrt * $0.00 Renewable* NO Automatic Renewal Grant ICA Department HUMAN SERVICES Department Email CM- HumanServices@weldgov.com Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WELD GOV.COM Requested BOCC Agenda Date* 04/15/2020 Due Date 04,11/2020 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Termination Notice Period Review Date* 04/01/2021 Committed Delivery Date Renewal Date Expiration Date* 05/3112021 Contact Information Contact Info Contact Name Purchasing Purchasing Approver Approval Process Department Head JAMIE ULRICH DH Approved Date 05/05/2020 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 05/13/2020 Originator SNYDERKL Contact Type Contact Email Finance Approver BARB C©NN©LLY Contact Phone 1 Contact Phone 2 Purchasing Approved Date Finance Approved Date 05/06/2020 Tyler Ref # AG 051320 Legal Counsel GABE KALOUSEK Legal Counsel Approved Date 05/06/2020 Submit CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND IDEA FQ1)UM_INC. This Agreement, made and entered into th day o 019, by and between the Board of Weld County Commissioners, on behalf of the Weld County Departme of Human Services, hereinafter referred to as the "Department' and IDEA Forum, Inc., 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 B1900025, which is incorporated into this agreement by reference and will be provided upon request to the Department. WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Services has provided Core Services or other funding to the Department for Domestic Violence Intervention, Mental Health Services, Monitored Sobriety Services, and Substance Abuse Treatment. 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, 2019, upon proper execution of this Agreement and shall expire May 31, 2020, unless sooner terminated as provided herein. The agreement is for a period of three years. However, the agreement must be renewed by both parties, in writing, on an annual basis. 2. Scope of Services Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibit B, Contractor's 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. OvLA3.e.a&O1S-O to -/a- /9 2019-2198 406`%v c. Contractor agrees to submit a complete Request for Reimbursement and supporting documentation by the 7th of the month, following the month of service, utilizing billing forms required by the Department. Contractor agrees to utilize the Client Verification Form for all scheduled and unscheduled face-to-face services with the exception of home studies and monitored sobriety testing. Contractor agrees that original complete Client Verification Forms are to be submitted with the Request for Reimbursement. Requests for Reimbursement and Client Verification Forms received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet 60 -day deadline may result in termination of the Agreement. d. Contractor agrees to submit a monthly report by the 7th of the month, following the month of service, for each client receiving ongoing services. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Date and time of service b. Where the service took place c. Clinician/therapist name d. Clients participating e. What interventions were used, recommendations and/or goals discussed f. Any and all safety concerns One-time services will be verified through receipt of the completed product (ex. psychological evaluation, substance abuse evaluation, home study). Verification of Monitored Sobriety Services will be the test result. A completed home study may be a full, partial or denied study, as determined by the Department. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under the Agreement. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately to the caseworker AND on the required monthly report. 4. Payment a. The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: i. The service being provided by the contractor is not a Medicaid eligible service; ii. The service is not deemed medically necessary; iii. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used; iv. A Medicaid provider is not available to provide the needed service; v. Medicaid is exhausted for the needed service; or vi. Medicaid denied service. vii. The client is not eligible for Medicaid. b. Payment shall be made in accordance with Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule, attached hereto and incorporated herein by reference, so long as services are rendered satisfactorily and in accordance with the Agreement. c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent upon, the continuing availability of said funds for the purposes hereof. 2 d. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 5. Financial Management 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 an, which will be provided by the Department, with a voided check. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. c. Contractor agrees to accept payment through county warrant when funding source does not allow for direct deposit. 7. Compliance with Applicable Laws a. At all times during the performance of this Agreement, Contractor will strictly adhere to all applicable Federal and State laws, order, and applicable standards, regulations, interpretations and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials that have been or may hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws and regulations, including, but not limited to the following: - Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and - all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, sex, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the approved Agreement. - Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and - the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and 3 - 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 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. 5 9. Insurance Requirements Contractor and the Department agree that Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of the Contractor, it subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. Contractor shall indemnify, defend and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Contractor shall provide the liability insurances (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteers, and agents engaged in the performance of this Agreement which are required under Weld County's Request for Proposal, and required by the Colorado Worker's Compensation Act. Contractor shall provide the Department with the acceptable evidence that such coverage is in effect within seven (7) days of the date of this Agreement. At a minimum, Contractor shall procure, either personally or through its employer as applicable to the Contractor's business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, State of Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible the insurance provider. a. General Requirements: Contractors must secure, at or before the time of execution of any agreement or commencement of any work, the following insurance covering all operations, goods or services provided pursuant to this request. Contractors shall keep the required insurance coverage in force at all times during the term of the Agreement, or any extension thereof, and during any warranty period. The required insurance shall be underwritten by an insurer licensed to do business in Colorado and rated by A.M. Best Company as "A"VIII or better. Each policy shall contain a valid provision or endorsement stating "Should any of the above -described policies by canceled or should any coverage be reduced before the expiration date thereof, the issuing company shall send written notice to the Weld County Director of General Services by certified mail, return receipt requested. Such written notice shall be sent thirty (30) days prior to such cancellation or reduction unless due to non-payment of premiums for which notice shall be sent ten (10) days prior. If any policy is in excess of a deductible or self -insured retention, the Department must be notified by the Contractor. Contractor shall be responsible for the payment of any deductible or self -insured retention. The Department reserves the right to require Contractor to provide a bond, at no cost to the Department, in the amount of the deductible or self -insured retention to guarantee payment of claims. The insurance coverages specified in this Agreement are the minimum requirements, and these requirements do not decrease or limit the liability of Contractor. Contractor shall maintain, at its own expense, any additional kinds or amounts of insurance that it may deem necessary to cover its obligations and liabilities under this Agreement. b. Types of Insurance: Contractor shall obtain, and maintain at all times during the term of any Agreement, insurance in the following kinds and amounts: i.Workers' Compensation Insurance as required by state statute, and Employer's Liability Insurance covering all of Contractor's employees acting within the course and scope of their employment. If Contractor is an Independent Contractor, as defined by the Colorado Worker's Compensation Act, this requirement shall not apply. Contractor must submit to the Department a Declaration of Independent Contractor Status Form prior to the start of this agreement. ii.Commercial General Liability Insurance written on ISO occurrence form CG 00 0110/93 6 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 as follows 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 970-400-6503 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 8 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 Marcela Paiz, 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: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970) 400-6510 9 For Contractor: Michelle Paiz, Owner 2370 West Alameda Avenue, Suite 8 Denver, CO 80223 (303) 477-8280 18. Litigation Contractor shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 17. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the Contractor is no longer available to the Department, or for any other reason. Contractor reserves the right to suspend services to clients if funding is no longer available. 20. No Third -Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental Immunity Act of §§24-10-101 et. seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more 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 10 not enter into any third -party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Contractor. A conflict of interest or appearance of a conflict of interest may also apply to personal relationships between providers and clients. If a provider has a personal relationship with a client to whom the Contractor may provide services for, the Contractor must disclose that relationship to the Department. Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of an Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records Contractor agrees that authorized local, Federal, and State auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement, to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by the Contractor in a central location and shall be made available to the Department upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the Federal and/or State government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records Contractor shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection. No information about or obtained from any applicant/recipient in possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with the Contractor's written policy governing access to, duplication and dissemination of, all 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. 11 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by the Contractor in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. 27. Independence of Contractor: Not an Employee of Weld County Contractor agrees that it is an independent Contractor and that Contractor's officers, agents or employees will not become employees of County, nor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall perform its duties hereunder as an independent Contractor. Contractor shall be solely responsible for its acts and those of its agents and employees for all acts performed pursuant to this Agreement. Contractor, its employees and agents are not entitled to unemployment insurance or workers' compensation benefits through County and County shall not pay for or otherwise provide such coverage for Contractor or any of its agents or employees. Unemployment insurance benefits will be available to Contractor and its employees and agents only if such coverage is made available by Contractor or a third party. Contractor shall pay when due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred pursuant to this Agreement. Contractor shall not have authorization, express or implied, to bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement. Contractor shall have the following responsibilities with regard to workers' compensation and unemployment compensation insurance matters: (a) provide and keep in force workers' compensation and unemployment compensation insurance in the amounts required by law, and as set forth in Exhibit A, provide proof thereof when requested to do so by County. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as state in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. The Contractor and the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 29. Agreement Nonexclusive This Agreement does not guarantee any work, nor does it create an exclusive agreement for services. 30. Warranty The Contractor warrants that services performed under this Agreement will be performed in a manner consistent with the professional standards governing such services and the provisions of this Agreement. The Contractor shall faithfully perform the work in accordance with the standards of care, skill, training, diligence 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. 12 31. Acceptance of Services Not a Waiver Upon completion of the work, the Contractor shall submit to the Department originals of all tests and results, reports, etc., generated during completion of this work. Acceptance by the Department of reports and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any action by the Department hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or default which may then exist on the part of the Contractor, and the Department's action or inaction when any such breach or default shall exist shall not impair or prejudice any right or remedy available to the Department with respect to such breach or default; and no assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any services performed under this Agreement shall not be construed as a waiver of any of the Department's rights under this Agreement or under the law generally. 32. Employee Financial Interest/Conflict of Interest. C.R.S. §§24-18-201 et seq. and §24-50-507 The signatories to this Agreement aver that to their knowledge, no employee of Weld County has any personal or beneficial interest whatsoever in the service or property which is the subject matter of this Agreement. The Contractor has no interest and shall not acquire any interest direct or indirect, which would in any manner or degree with the performance of the Contractor's services and the Contractor, shall not employ any person having such known interests. During the term of this Agreement, the Contractor shall not engage in any in any business or personal activities or practices or maintain any relationships which actually conflicts with or in any way appear to conflict with the full performance of its obligations under this Agreement. Failure by the Contractor to ensure compliance with this provision may result, in the Department's sole discretion, in immediate termination of this Agreement. No employee of the Contractor nor any member of the Contractor's family shall serve on a County Board, committee or hold any such position which either by rule, practice or action nominates, recommends, supervises Contractor's operations, or authorizes funding to the Contractor. 33. Board of County Commissioners of Weld County Approval This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado. 34. Choice of Law/Jurisdiction Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 35. Subcontractors Contractor acknowledges that the Department has entered into this Agreement in reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the completion of this project without the Department's prior written consent, which may be withheld in the Department's sole discretion. 13 36. Attorney's Fees/Legal 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, 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. 14 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: �, Weld • u ty Clerk to the Board By Deputy Clerk to j e Bo • rd ok, 15 BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO arbara Kirkmeyer, Chair JUG{ 12 2019 CONTRACTOR: IDEA Forum, Inc. 2370 West Alameda Avenue, Suite 8 Denver, CO 80223 (303) 477-8280 By: Date: Nanda Marcela Peiz (Apr 25, 2019) Marcela Paiz, Owner Apr 25, 2019 Q01R- 0198' 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. CONTRAC S RE O IDEA Denver 2370 W. Alameda Ave. Ste 8 Denver, CO 80223 p. 303.477.8280 f. 303.477.1369 denverfd@ideacares.com January 25th, 2019 CHARTING IDEA Aurora 14311 E. 4th Ave. Aurora, CO 80011 p. 720.949.0095 f. 720.949.2005 aurorafdOideacares.com IT PROPOSAL A NEW COURSE IDEA Brighton 83 N. 4th Ave. Brighton, CO 80601 p. 303.659.9440 f. 303.659.9430 brightonfdOideacares.com IDEA Thornton 9051 Washington St. Thornton, CO 80229 p. 303.996.9966 f. 303.996.9954 thorntonfdOideacares.com Enclosed is the response to RFP B-1900025. IDEA bid is to provide services as a contractor with Weld County Department of Human Services: 1) Domestic Violence/Anger Management 2) Substance Abuse Treatment Services — Billable to Medicaid (IDEA is a Medicaid Approved Provider) IDEA continues to provide quality evaluations and treatment utilizing Evidence Based Practices (EBP) for which therapists have been trained and certified. IDEA therapists have been trained in providing trauma informed care and are certified to provide treatment in Helping Men Recover and Seeking Safety. Clients are assessed for trauma histories and for the impact of trauma on their behaviors. Helping Men Recover and Seeking Safety address trauma triggered thinking and behaviors. IDEA service providers are culturally sensitive and bilingual, proficient in English and Spanish. We provide gender specific treatment to adults and adolescents and LGBTQ. We have Certified Addiction Counselors (CAC) as well as DVOMB Approved Domestic Violence Treatment Providers to facilitate Substance abuse treatment and Domestic Violence treatment respectively. Monitored sobriety services at IDEA include Urinalysis (UA), Breathalyzers (BA), hair tests, and swab tests. IDEA office hours are sensitive to client needs, open from 9:00am to 9:00pm. IDEA provides services at the four locations listed above. Referring agents are provided reports on the frequency and formats requested. Enclosed Items 1) Provider Information Form 2) IDEA Proposal 3) IDEA Staff Data Sheet 4) Certificate of Insurance (COI) 5) IDEA W9 W W W. 1 D E A C A R E S. C O M EXHIBIT B PROVIDER INFORMATION FORM Weld County Department of Human Services IDEA Forum Inc. AGENCY OR PRIVATE PRACTICE TRAILS PROVIDER ID (If Known) Marcela Paiz PRIMARY CONTACT —FULL NAME (303) 477 8280 PHONE NUMBER mpaiz@ideacares.com PRIMARY CONTACT- E-MAIL ADDRESS 2370 W Alameda Ave St 8 Owner PRIMARY CONTACT - TITLE (303) 477 1369 EXT. FAX NUMBER www.ideacares.com AGENCY/PRACTICE WEB ADDRESS (IF APPLICABLE) Denver CO 80223 AGENCY MAILING ADDRESS CITY ZIP Miguel Avina REFFERAL CONTACT— FULL NAME (303) 477 8280 REFERRAL CONTACT— PHONE NUMBER REFERRAL CONTACT EXT. COO REFERRAL CONTACT - TITLE referral@ideacares.com REFERRAL CONTACT — E-MAIL ADDRESS Rachel Montoya BILLING CONTACT —FULL NAME (303) 477 8280 BILLING CONTACT— PHONE NUMBER EXT. BILLING CONTACT CFO BILLING CONTACT - TITLE billing@ideacares.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 competitive in price and quality. Signature of Authorized Representative: Date of Signature: Bid No.: B1900025 EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: 2. Program name or service type being proposed: IDEA Forum Inc. Child Protection Various Services 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. • DV Evaluation and Treatment • Substance Use Disorder Evaluation and Treatment • DUI Education and Treatment • Anger Management • Adult Responsibility • Victim Empathy • Parenting • Life Skills 4. Capacity to Provide Services (ex. 4 hours/week). IOP — 9+ Hours/Week 5. Goals of the service. To identify, and address risks and need of the client and increase skills for relationships and parenting. 6. Outcomes of service. Reduction or elimination of harm to self or others, recovery work in victim empathy, accountability in safe an secure relationships. 7. Target population for service. Ages: 14-99 Gender: Male and Female Specific Treatment Sexual Orientation: LGBTQ Services Offered Languages: English, Spanish, ASA 8. Service access. In office/In Person IDEA Denver 2370 W Alameda Ave. Ste 8 Denver, CO 80223 IDEA Aurora 14311 E 4th Ave. Aurora, CO 80011 IDEA Brighton 83 N 4th Ave. Brighton, CO 80601 IDEA Thornton 9051 Washington St Thornton, CO 80229 Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE 9. Languages service is available in. ENGLISH SPANISH All languages accepted with Translator 10. Rates of service. Service Unit Fee Domestic Violence Intake Evaluation Episode X $80 Domestic Violence Group Episode 2 Hours $35 Standard Group Therapy Episode 2 Hours $35 Individual Therapy Episode 1 Hour $65 Adolescent Group Therapy Episode 2 Hours $30 Adolescent Individual Therapy Episode 1 Hour $45 Family Therapy Episode 1 Hour $65 EMDR Eye Movement Desensitization and Reprocessing Episode 1 Hour $80 Substance Use Evaluation Episode X $150 Substance Use Intake Assessment Episode X $50 Anger Management Evaluation Episode X $125 Monitored Sobriety Unit Fee 7 Panel Urinalysis Episode X $17 Steroid Urinalysis Episode X $165 Swab Test Episode X $25 Hair Test Episode X $75 Breathalyzer Episode X $10 Each service is billable only one time per day. Bid No.: 1900025 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 services.) PROPOSED SERVICE OR SERVICE TYPE: Domestic Violence/SUD/General Treatment Therapy Services BIDDER LEGAL ENTITY NAME: IDEA Forum Inc. APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION VISOR iraFORIDATiQN No. Last Name First Name Work# Work Email Education Level Degree Focus Licensure/ Credentials DORA # III applicable) LastName ₹ Tame Mut ., 1 Williams Abbey 3034778280 awilliams@ideacares.com BA CAC III, ATP ACC.0020861 Paiz Marcela 303 477 8280 2 Zambrano Alicia 3034778280 azambrano@ideacares.com CAC ACA.0007145 Paiz Marcela 303 477 8280 3 Barrett Ana 3034778280 abarrett@ideacares.com BS CAC I, ADVTP ACA.0007586 Paiz Marcela 303 477 8280 4 Villa Arturo 3034778280 avilla@ideacares.com BA CAC, III, ATP ACC.0004304 Paiz Marcela 303 477 8280 5 Hernandez Andrea 3034778280 ahernandez@ideacares.com BS CAC I ACA.0007720 Paiz Marcela 303 477 8280 6 Johns Charlie 3034778280 ciohns@ideacares.com MA LPC, CAC III, A MT.o010131 Paiz Marcela 303 477 8280 7 Picone Covin 3034778280 cpicone@ideacares.com CAC II, ATP AC8.0007220 Paiz Marcela 303 477 8280 8 McCubbin Crystal 3034778280 cmccubbin@ideacares.com BS CAC II, ADVTP ACB.0008116 Paiz Marcela 303 477 8280 9 Lozano Diana 3034778280 dlozano@Ideacares.com BA CAC I, ADVTP ACA.0006772 Paiz Marcela 303 477 8280 10 Tygart Deidre 3034778280 dtygart@ideacares.com CAC III, ATP ACC.0006214 Paiz Marcela 303 4778280 11 Clavijo Frank 3034778280 fclaviio@ideacares.com PhD Psychology LPC, CAC III, A ACC.0006304 Paiz Marcela 303 477 8280 12 Hernandez Jacob 3034778280 jhernandez@ideacares.com CAC III, PRC, A ACC.0007042 Paiz Marcela 303 477 8280 13 Polk Jason 3034778280 jpolk@ideacares.com ACD.0000426 Paiz Marcela 303 477 8280 14 Blacklock Jaurene 3034778280 jblacklock@ideacares.com MA LPC, CAC III, A LPC.0006278 Paiz Marcela 303 477 8280 15 Mancha John 3034778280 jmancha@ideacares.com BSW CAC III, ATP ACC.0003722 Paiz Marcela 303 477 8280 16 Rhodes John 3034778280 jrhodes@ideacares.com CAC II, ATP ACB.0007411 Paiz Marcela 303 477 8280 17 Soto -Arroyo Juana 3034778280 jsoto@ideacares.com CAC II ACB.0008262 Paiz Marcela 303 477 8280 18 Rivera Laura 3034778280 Irivera@ideacares.com MA CAC I, LPC, NC LPC.0014500 Paiz Marcela 303 477 8280 19 Johnson Linda Carol 3034778280 Iiohnson@ideacares.com BA CAC III, ATP ACC.0020931 Paiz Marcela 303 477 8280 20 Paiz Marcela 3034778280 mpaiz@ideacares.com BS Human Service: CAC III, CCTP, ACC.0004855 Paiz Marcela 303 477 8280 21 Arroyo Maria 3034778280 marroyo@ideacares.com BS CAC III, ADVTI ACC.0005114 Paiz Marcela 303 477 8280 22 Castro Mario 3034778280 mcastro@ideacares.com BS CAC III, ATP ACC.0020906 Paiz Marcela 303 477 8280 23 Hernandez Margaret 3034778280 mherandnez@ideacares.com MA CAC II, MFTC, MFTC.0013610 Paiz Marcela 303 477 8280 24 Jarvis Matthew 3034778280 mjarvis@ideacares.com MA LAC, NCC, ATF LPC.0014401 Paiz Marcela 303 477 8280 25 Williams Michael 3034778280 mwilliams@ideacares.com MA LPC, ATP LPC.0014602 Paiz Marcela 303 477 8280 26 Ortiz -Moreno Nancy 3034778280 nortiz@ideacares.com MA CAC III, ADVTIACC.0020821 Paiz Marcela 303 477 8280 27 Marquez Naomi 3034778280 nmarquez@ideacares.com CAC I ACA.0007529 Paiz Marcela 303 477 8280 28 Suarez Raul 3034778280 rsuarez@Ideacares.com BA CAC III, ATP ACC.0006855 Paiz Marcela 303 477 8280 3034778280 Paiz Marcela 303 477 8280 Bid No.: 01900025 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 services.) Porras Renato 3034778280 rporras@ideacares.com BS CAC ACA.0007757 Uceda Robert Hawkins Sam DeCarolis Sandra Fellers Sara Hawkins Sharon Jacobsen Theresa Saldana Yvonne Bid No.: B1900025 3034778280 3034778280 3034778280 3034778280 3034778280 3034778280 3034778280 ruceda@ideacares.com MA LAC, ATP ACD.0000293 samhawkins@ideacares.com CAC II AC8.0008156 sdecarolis@ideacares.com MA LPC, NCC LPC.0014106 sfellers@ideacares.com MA LAC, ATP ACD.0000434 shawkins@ideacares.com CAC III ACC.0000955 taacobsen@ideacares.com BA CAC II, ATP ACC.0001638 ysaldana@ideacares.com MSW Social Work CAC III, ADVTI ACC.0006809 Paiz Marcela 303 477 8280 Paiz Marcela 303 477 8280 Paiz Marcela 303 477 8280 Paiz Marcela 303 477 8280 Paiz Marcela 303 477 8280 Paiz Marcela 303 477 8280 Paiz Marcela 303 477 8280 Paiz Marcela 303 477 8280 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 services.) Work mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@tdeacarescom mpaiz@ideacarescorn mpaiz@ideacarescom mpaiz@ideacares.com mpaiz@ideacarescom mpaiz@ideacarescom mpaiz@deacares.com mpaiz@ideacarescom mpaiz@ideacarescom mpaiz@ideacares.com Bid No.: B1900025 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 services.) mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com mpaiz@ideacares.com Bid No.: 01900025 A4 ®p�® L. -----CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 9/11/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER SterlingRisk 135 Crossways Park Drive P.O. Box 9017 Woodbury NY 11797 CONTACT PHONE I FAX INC. No. Ext): 800-735-1588 (A/C, No): 888.290-0302 ADDRESS: SelectCertRequests@sterlingrisk.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Granite State Insurance Company 23809 INSURED IDEAF-1 Idea Forum, Inc. 2370 West Alameda Avenue - Suite 8 Denver CO 80223 INSURER a: Beaztey Insurance Company, Inc. 37540 INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 316074606 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR rypE OF INSURANCE ADDL ,(NSD SUBR WVD POLICY NUMBER POLICY EFF IMMIODNYYY) POLICY EXP (MM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y 02LX00738386814000 8/14/2018 8/14/2019 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE XOCCURDAMAGE TO RENTED PREMISES (Ea occurrence) $ 5,000 MED EXP (Any one person) $ 100,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,00D GEN'LAGGREGATE X POLICY OTHER' LIMIT APPLIES PRO JECT PER: LOC PRODUCTS - COMP/OP AGG $1,000,000 $ AUTOMOBILE _ LIABILITY ANY AUTO ALL OVVNED SCHEDULED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Par accident) $ PROPERTY DAMAGE (Per acoldent) $ UMBRELLA LIAB EXCESS LIAB ` OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEMIEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below YIN N 1 A PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A B Professional Liability Cyber Liab-Claims Made Continuity Date 11/25/13 02LX00738386814000 W17365150401 8/14/2018 11/25/2017 8/14/2019 11/25/2018 Occurence $1,000,000 Aggregate $3,000,000 Cyber •Aggregate $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS (VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Certificate Holder is included as Additional Insured as per endorsement form CG20260413 to the extent provided therein. CERTIFICATE HOLDER CANCELLATION City & County of Denver 1331 Cherokee Street Denver, CO 80203 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 {2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The AGGRO name and logo are registered marks of ACORD ,9 I orm W (Rev. October 2018) Department of the treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification ► Go to www.irs.gov/FormW9 for instructions and the latest information. Give Form to the requester. Do not send to the IRS. co O) o. o w ti c a_ O .''1 p 2 in e e a g U a5 1 Name do rot leave this line blank. /(as �s'ho n on your ncome lax return). Name ,//iis reeguiiirred on this line; } 2 Business name/disregarded entity name, it different from above 3 Check appropriate following seven boxes. ❑ Individual/sole single -member ❑ Limited liability Note: Check the tIC if the I LC another I_LC that is disregarded box for federal lax classification of the person whose name is entered on line 1. Check �/ only one of the ❑ Trust/estate I. 4 Exemptions certain entities, Instructions Exempt payee Exemption code ( If an rMu lies to accounts (codes apply only to not individuals; see on page 3): code (if any) proprietor or ❑ C Corporation S Corporation Partnership LLC company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) appropriate box in the line above for the tax classification of the single -member owner. is classified as a single -member I I C that is disregarded from tho owner unless the owner is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single from the owner should check the appropriate box for the tax classification of its owner. I. from FATCA reporting y) Do not check of the I_LC is -member LLC that maintained outside the U.S.)m � Other (see instructions) Address (number, street, am' apt. or suite no.) See instructions. e 4 510 � r AZ -A -M �TJil- ,47J�` . STE: 0 Requester's name and address (optional) 6 City, state, and LIP code —3>e--70 0 r6E-- S?0 ,A�;3 7 I ist account number(s) here (optional) part! Taxpayer Identification Number (TIN) Linter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). I lowever, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see /low to get a 11N, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number J or Employer identification number r- 0 b 0 5 3 LEM Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the c. I u•tion, but you must provide your correct TIN. See the instructions for Part II, later. Sign Here Signature of U.S, person ► G(J 1 General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (f=orm W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099 -IN I (interest earned or paid) Date ► 11//' 8-v 6),D • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-F (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10 7.018} BEFORE THE COLORADO ADDICTION COUNSELOR PROGRAM STATE OF COLORADO Case No. 2006-003078 STIPULATION AND FINAL AGENCY ORDER IN THE MATTER OF DISCIPLINARY PROCEEDINGS REGARDING THE CERTIFICATE TO PRACTICE ADDICTION COUNSELING IN THE STATE OF COLORADO OF MARIA R. ARROYO-CHACON, CAC III, LICENSE # 5114 RESPONDENT. IT IS HEREBY STIPULATED by and between the Colorado Addiction Counselor Program ("Director") and Maria R. Arroyo-Chacon, CAC III ("Respondent") as follows: 1. The Director has jurisdiction over the person of Respondent, her certificate to practice, and the subject matter of this stipulation. 2. Respondent was certified to practice as an addiction counselor in the State of Colorado at all relevant times herein and is now so certified, 3. Respondent admits the following: a. On July 3, 2005, Respondent pled guilty to DWAI in the Adams County District Court, docketed as case number 05T9994. 4`. By virtue of the admissions in paragraph 3, Respondent agrees that she is in violation of C.R.S. §§ 12-43-222 (1)(g) and (e). 5. The statutory authority of the Director is as follows: 12-43-222. Prohibited activities — related provisions. (1) A person licensed, registered, or regulated under part 3, 4, 5, 6, or 7 of this article is in violation of this article if such person: (e) Is habitually intemperate or excessively uses any habit-forming drug or is a habitual user of any controlled substance, as defined in section 12-22- 203(7), or any alcoholic beverage of which renders him or unfit to practice pursuant to parts 3, 4, 5, 6, or 7 of this article; (g) Has acted or failed to act in a manner that does not meet the generally accepted standards of the professional discipline under which such person practices. A certified copy of a malpractice judgment of a court of competent jurisdiction shall be conclusive evidence of such act or omission, but evidence of such act or omission shall not be limited to a malpractice judgment. PROBATION 7. Respondent's certificate to practice addiction counseling in the State of Colorado is hereby placed on probation for two (2) years commencing from the date this Order is fully executed or the date Respondent's practice monitor is approved, whichever date is later. During the probationary period, Respondent shall be bound by the terms and restrictions set forth in this Order. 8. The period of probation is tolled during any time that Respondent is not practicing addiction counseling in this state, and such period of probation shall resume at such time as Respondent resumes practicing in the State of Colorado in accordance with this Order. 9. Credit toward the period of probation will be given only for the period of time during which Respondent is practicing as a Certified Addiction Counselor in Colorado, is being monitored by a practice monitor and is in full compliance with all terms of this Order. 10. If, at the end of the probationary period, Respondent has adhered to all terms and conditions of this Order, Respondent may request termination of probation. Request for termination of probation must be made in writing to the Director, and Respondent is responsible for establishing, to the satisfaction of the Director, that she has satisfied all terms and conditions of probation. PRACTICE MONITOR l 1. During the term of probation, Respondent's practice shall be monitored by a practice monitor. Within 30 days of the effective date of this Order, Respondent shall submit, in writing, three proposed practice monitors for the Director's approval. Respondent shall include a program -approved practice monitor application from each potential monitor, with attached curriculum vita or resume. The practice monitor shall meet the following criteria: a. The practice monitor shall be a licensed, certified, or listed, currently practicing mental health provider in the State of Colorado. b. It is recommended that the practice monitor have a minimum of five years experience and has not been subject to professional discipline. 2 c. The practice monitor shall have no current or past financial or personal interest in Respondent or Respondent's practice. Former employees and business associates fall under this provision. 12. Respondent must have a practice monitor approved by the Director within two months after this Order is fully executed. If this requirement is not satisfied, Respondent must cease practice and agrees to suspension of her practice until a practice monitor is approved. 13. After the Director's written approval of the practice monitor, Respondent and the practice monitor shall enter into a written contract for monitoring. The practice monitor shall provide a copy of the written contract to the Director as a part of her first report to the Director. The contract must contain a provision stating that the practice monitor has received a copy of this Order, the complaint and responsive documents, any investigative report, and any prior practice evaluation; has read these documents; and understands the duties and responsibilities she is undertaking as Respondent's practice monitor. The practice monitor shall ensure that a written notification is provided to each of Respondent's clients, informing the clients of the name, address, and telephone number of the practice monitor. This written notification may be provided in a mandatory disclosure statement. 14. The practice monitor shall conduct a practice evaluation during the first month of practice monitoring. The practice evaluation shall examine all aspects of Respondent's practice or proposed practice and her qualifications and ability to practice in accordance with generally accepted standards of practice and with skill and safety for clients, and determine whether she has the necessary qualifications, current ability, and competence to practice. The first practice monitoring report shall include the findings of the practice evaluation. 15. Should the Director determine from the practice monitor's evaluation that Respondent cannot practice any part of her practice with skill and safety for clients in accordance with generally accepted standards of practice or does not have the appropriate qualifications, ability or competence for practice, Respondent shall immediately cease any part of the practice that the Director determines, based on the evaluation, she is not qualified, competent, or safe to conduct. Based on the Director's findings and the evaluation, the Director will determine necessary actions that Respondent must take and conditions Respondent must meet so that Respondent can practice with skill and safety for clients in accordance with generally accepted standards of practice in any areas the Director finds Respondent is not qualified, competent, and safe to practice. Once Respondent satisfies the Director that she is qualified, competent, and safe to fully practice, Respondent may resume full practice. 16. The practice monitoring shall consist of individual, in -person (face-to-face) sessions that occur once a week for at least one hour, or such longer time as the practice monitor deems necessary. During the practice monitoring sessions, Respondent and her practice monitor must review and discuss each of Respondent's active cases at least once every month in order to allow the practice monitor to be able to determine whether 3 Respondent is practicing addiction counseling in accordance with generally accepted standards of practice and with skill and safety for her clients. 17. The practice monitor shall submit written reports to the Director on the fifth day of the month following the first full month of practice monitoring. All subsequent reports shall be submitted on the fifth day of each month for the first 12 reports. 18. If at any time the Director has questions or concerns regarding the monitoring, the practice monitor agrees to attend any Director meeting necessary to address the Director's concerns. The Director will give the practice monitor 30 days notice prior to requiring the practice monitor's attendance at the Director meeting. 19. If at any time the practice monitor believes Respondent is not in compliance with this Order, is unable to practice with skill and safety to her/his clients, or has committed a violation of the practice act or rules and regulations, the practice monitor shall immediately notify the Director, in writing, and include the basis for this conclusion. A copy will be sent to Respondent. Upon submission of such a report, Respondent shall immediately cease the practice of addiction counseling. 20. Respondent shall make every effort to ensure that all reports by the practice monitor are complete and timely submitted to the Director. If, in the Director's judgment, the practice monitor fails to perform the function specified by this Order, the Director may require that a new practice monitor assume the responsibilities herein. If for any reason the practice monitor ceases to perform the functions specified in this Order, Respondent shall submit, in writing, a new proposed practice monitor to the Director within 30 days. 21. Respondent or the practice monitor may terminate the monitoring relationship upon written notice to the other and to the Director not less than 60 days before the date of termination. The notice shall state the reason for the termination. Respondent shall immediately initiate efforts to obtain another Director -approved practice monitor, who shall conduct her/his monitoring and report to the Director in accordance with this Order. CONTINUING EDUCATION 23. During the period of probation, Respondent must successfully complete at least twenty (20) hours each year of Director -approved professional continuing education courses in the areas of Substance Abuse, Relapse Prevention, Boundary Issues, Legal/Ethical Issues relating to the practice of addiction counseling. Respondent shall obtain Director approval of the courses prior to enrolling in each course. Upon completion of a course, the provider is to mail to the Director a certificate of completion. 4 TERMS AND CONDITIONS 24. Respondent is fully aware of and understands the right to receive a formal notice of hearing and charges and to have a formal disciplinary hearing, pursuant to C.R.S. § 12-43-224, and hereby waives those rights. Further, Respondent also acknowledges that this waiver constitutes a waiver of all rights to appeal in this matter. 25. This Order is entered into by Respondent voluntarily and without coercion, after an opportunity to consult with counsel and with full understanding of the legal consequences of this Order and the right to formal hearing on all matters herein. 26. The Order entered pursuant to this Stipulation and Final Agency Order shall constitute a Director order for purposes of C.R.S. §12-43-222, and shall have the same force and effect as an order entered after a formal disciplinary hearing pursuant to C.R.S. §12-43-224. 27. This Order constitutes the entire agreement between Respondent and the Director. There are no other promises expressed or implied. In the event that any provision of this Order is deemed unenforceable by a court of competent jurisdiction, such provision shall be severed, and the remainder of this Order shall be given full force and effect. 28. This Order shall become effective when accepted and signed on behalf of the Director. 29. This Order shall be a public record in the custody of the Director. RESPONDENI' Maria R. afic2z7 o-Chacon, CAC ID COLORADO ADDICTION COUNSELOR PROGRAM 9/(C -C -;e'-6_ Director Effective Date: This a day of 2007. 5 John W. Hickeniooper Governor Barbara J. Kelley Executive Director Dora Department of Regulatory Agencies June 21, 2011 Frank Claviio, CAC III Division of Registrations Rosemary McCool Director RE: Complaint Filed By DVOMB Case #2010-004715 (CAC) Letter of Admonition Mental Health Programs Ronne M. Hines Program Director Dear Mr. Clavijo: On June 7, 2011, the Division Director for the Office of Addiction Counselors ("Director") reviewed the available material concerning the above referenced case. After thorough review, the Director found probable cause to believe you violated CRS 12-43-216, 12-43-222(1) (g), and (n), and issued this Letter of Admonition in accordance with CRS 12-43-224(3)(d). Specifically, the Director determined: • You violated DVOMB standards 5.01 and statute 16-11.8-104 CRS by allowing non -approved DVOMB individual to provide domestic violence offender treatment. By this letter, the Director takes the formal disciplinary action of admonishing you for the conduct specified above, and warns you that repetition of such practice may lead to imposition of more severe disciplinary action. This letter is an open public record and a reportable action to individuals or entities requesting disciplinary information. The Director strongly encourages you to review and understand the Mental Health Practice Act requirements and obligations for the practice of addiction counseling/psychotherapy in Colorado. In accordance with CRS 12-43-224(3)(d), the Director advises you that you have the right to make a written request that the Director initiate formal disciplinary proceedings in order to adjudicate the conduct or acts upon which this letter is based. You must make your written request within twenty (20) days after receipt of this letter and address your request to Ronne M. Hines, Program Director, at the address listed below. If you make a timely request, the Director will deem this letter of admonition vacated and may proceed with disciplinary and/or injunctive proceedings in accordance with CRS 12-43-224(3)(d), and applicable rules. If this letter is not vacated, it will become the final agency action in this matter. Sincerely, FORE OFFICE OF ADDICTION COUNSELORS Ronne M. Hines Program Director RMH/vm 1560 Broadway, Suite 1350 Denver, Colorado 80202 Phone 303.894.7800 Fax 303.894.7764 www.dora.state.co.us V/TDD 711 Consumer Protection Division of Registrations Mental Health Programs Gregory Feriand Ronne M. Hines Interim Division Director Program Director +�?e,,.' Department of Regulatory Agencies John W. Hickenlooper Governor Barbara J. Kelley Executive Director MAILED CERTIFIED MAIL February 22, 2012 Robert "Charlie" Johns, LPC, CAC 11•111111me RE: Case #2011-004532 (LPC), 2011-004533 (CAC) Dear Mr. Johns: On January 13, 2012, the State Board of Licensed Professional Counselor Examiners (Board) reviewed the available material concerning case # 2011-004532. Additionally on January 17, 2012, the Board of Addiction Counselor Examiners (Board) reviewed the available material concerning case # 2011-004533. After thorough review, the Boards found probable cause to believe you violated CRS 12- 43-222(1)(b) and issued this Letter of Admonition in accordance with CRS 12-43- 224(3)(d). Specifically, the Board determined that you were in violation of a Board Order concerning case # 2010-001101 and # 2010-001380 which resulted in a stipulation and final agency order effective March 4, 2011. Per this order, you were not to practice without a practice monitor in place and you were required to update your address within thirty days of any change. By this letter, the Board takes the formal disciplinary action of admonishing you for the conduct specified above, and warns you that repetition of such practice may lead to imposition of more severe disciplinary action. This letter is an open public record and a reportable action to individuals or entities requesting disciplinary information. The Board strongly encourages you to review and understand the Mental Health Practice Act requirements and obligations for the practice of professional counseling/psychotherapy and addiction counseling in Colorado. In accordance with CRS 12-43-224(3)(d), the Board advises you that you have the right to make a written request that the Board initiate formal disciplinary proceedings in order to adjudicate the conduct or acts upon which this letter is based. You must make your written request within twenty (20) days after receipt of this letter and address your request to Ronne M. Hines, Program Director, at the address listed below. If you make a timely request, the Board will deem this letter of admonition 1560 Broadway, Suite 1350 Denver, Colorado 80202 Phone 303.894.7800 Fax 303.894,7764 www.dora.state.co.us V/TDD 711 AIM ConsumProtection vacated and may proceed with disciplinary and/or injunctive proceedings in accordance with CRS 12-43-224(3)(d), and applicable rules. If this letter is not vacated, it will become the final agency action in this matter. Sincerely, FOR THE STATE BOARD OF LICENSED PROFESSIONAL COUNSELOR EXAMINERS AND THE STATE BOARD OF ADDICTION COUNSELOR EX ADd INERS Ronne M. Hines Program Director cc: Robert Lees RH/ja t BEFORE THE COLORADO BOARD OF LICENSED PROFESSIONAL COUNSELOR EXAMINERS AND THE COLORADO ADDICTION COUNSELOR PROGRAM STATE OF COLORADO CASE NOS.: 2010-001101 & 2010-001380 STIPULATION AND FINAL AGENCY ORDER IN THE MA I FER OF DISCIPLINARY PROCEEDINGS REGARDING THE LICENSE TO PRACTICE PROFESSIONAL COUNSELING AND THE CERTIFICATE TO PRACTICE ADDICTION COUNSELING IN THE STATE OF COLORADO OF ROBERT (CHARLIE) JOHNS, LICENSE NO. LPC 3108 AND CERTIFICATE NO. 1348, Respondent. IT IS HEREBY STIPULATED by and between the Colorado Board of Licensed Professional Counselor Exaininers ("Board"), Colorado Addiction Counselor Program ("Director") and Robert (Charlie) Johns ("Respondent") as follows: 1. The Board and Director have jurisdiction over the person of Respondent and the subject matter of this Stipulation and Final Agency Order ("Order"). 2. Respondent was licensed to practice as a Professional Counselor and certified to practice as an Addiction Counselor III in the State of Colorado at all times relevant herein. 3. Respondent is not currently engaged in the practice of professional counseling or addiction counseling in Colorado. 4. This Order is a full and final resolution of Case Numbers 2010-001101 and 2010- °01380. This Order does not resolve any other cases, complaints, or matters, known or unknown to the Board, Director or Respondent, as of the effective date of this Order. S. Respondent admits the following: a. Respondent allowed interns/trainees to conduct intakes and facilitate domestic violence offender treatment groups without being approved Domestic Violence Offender Management Board (DVOMB) providers. b. Respondent failed to provide proper supervision to the intents/trainees in question. 6. By virtue of the facts admitted in paragraph 5 above, the Board and Director find that Respondent violated Sections 12-43-222(1)(g) and (n), C.R.S., and DVOMB Standards 4.02 and 5.03. 7. By virtue of paragraphs 5 and 6, Respondent is subject to the following disciplinary sanction(s) that the Board and Director believe is necessary to protect the public health, safety, and welfare. 8. Respondent is not currently practicing professional counseling or addiction counseling in Colorado. Should Respondent seek to resume the practice of professional counseling and/or addiction counseling, he trust first notify the Board and Director in writing of his intent to resume practice in the state. 9. Prior to resuming the practice of professional counseling and/or addiction counseling in Colorado, Respondent shall obtain a Board and Director -approved practice evaluator who will conduct a practice evaluation. Respondent shall nominate three proposed practice evaluators for Board and Director approval consistent with paragraphs 12 and 13. The practice_ evaltiatik,inay= also be Respondent's practice monitor should the Board and Director aGtho`r z spotident to resume�practice in Colorado. The practice evaluation shall examine all 'ispeets=-of Respondent's practice or proposed practice and his qualifications and ability to practice in accordance with generally accepted standards of practice and with skill and safety for clients, and determine whether he has the necessary qualifications, current ability, and competence to practice. The findings of the practice evaluation shall be submitted to, and accepted by, the Board and Director. Respondent shall not perform any act requiring a license to practice professional counseling or addictioncounseling in Colorado until such time as the Board and Director have accepted the practice evaluation, authorized Respondent to resume practice in Colorado, and approved Respondent's practice monitor. 10. Should the Board and Director determine from the evaluation that Respondent -cannot practice any part of his practice with skill and safety for clients in accordance with generally accepted standards of practice or does not have the appropriate qualifications, ability or competence for practice, Respondent shall not be allowed to resume the practice of professional counseling and/or addiction counseling or any portion of the practice of professional counseling and/or addiction counseling that die Board and Director determine, based on the evaluation, he is not qualified; competent, or sate to conduct. Based on the Board and Director's findings and the evaluation, the Board and Director will determine necessary actions that Respondent must take and conditions Respondent must meet so that Respondent can practice with skill and safety for clients in accordance with generally accepted standards of practice in any areas the Board and Director Lind Respondent is not qualified, competent, and safe to practice. Once Respondent satisfies the Board and Director that he is qua.titied, competent, and safe to fully practice, Respondent may resume full practice. 11. Should the Board and Director authorize Respondent to resumepractice in Colorado after review of the practice evaluation, Respondent's license to practice professional counseling and certification to practice addiction counseling in the State of Colorado shall he placed on probation for one (t) year commencing from the date that the Board and Director 2 authorizes Respondent to resume practice. During the probationary period, Respondent shall be bound by the terms and restrictions set forth below. PROBATIONARY TERMS SHOULD RESPONDENT RESUME PRACTICE 12. During the term of probation, Respondent's practice will be monitored by a practice monitor. Respondent shall submit, in writing, three proposed practice monitors for the Board and Director's approval. Respondent shall include an approved practice monitor application form from each potential monitor, with attached curriculum vita or resume. The practice monitor shall meet the following criteria: a. The practice monitor shall be a licensed, certified, or listed, currently practicing mental health provider in the State of Colorado. b. It is recommended that the practice monitor have a minimum of five years experience and has not been subject to professional discipline. • c. The practice monitor shall have no current or past financial or personal interest in Respondent or Respondent's practice. Former employees and business associates fall under this provision. 13. After the Board and Director's written approval of the practice monitor, Respondent and the practice monitor shall enter into a written contract for a practice monitoring. The practice monitor shall provide a copy of the written contract to the Board and Director as a part of his/her first practice monitoring report to the Board and Director. The contract must contain a provision stating that the practice monitor has received a copy of this Order, the complaint and responsive documents, any investigative report, and the practice evaluation; has read these documents; and understands the duties and responsibilities s/he is undertaking as Respondent's practice monitor. The practice monitor shall ensure that a written notification is provided to each of Respondent's clients, informing the clients of the name, address, and telephone number of the practice monitor. This written notification may be provided in a mandatory disclosure statement. 1,1. The practice monitoring shall consist of individual, in -person (face-to-face) sessions that occur for one hour, or such longer time as the practice monitor deems necessary, for every 20 hours of client contact, but at least once a month. During the practice monitoring sessions, Respondent and his practice monitor must review and discuss each of Respondent's active cases at least once every month in order to allow the practice monitor to be able to determine whether Respondent is practicing professional counseling and/or addiction counseling in accordance with generally accepted standards of practice and with skill and safety for his clients. 15. The practice monitor shall submit written reports to the Board and Director on the fifth day of the month following the first full month of practice monitoring. All subsequent reports shall be submitted on the fifth day of each month for the remainder of the probationary period. 16. If at any time the Board or Director has questions or concerns regarding the monitoring, the practice monitor agrees to attend any Board or Director meeting necessary to address the Board or Director's concerns. The Board or Director will give the practice monitor 30 days notice prior to requiring the practice monitor's attendance at the Board or Director meeting. 17. If at any time the practice monitor believes Respondent is not in compliance with this Order, is unable to practice with skill and safety to his clients, or has committed a violation of the practice act or rules and regulations, the practice monitor shall immediately notify the Board and Director, in writing, and include the basis for this conclusion. A copy will be sent to Respondent. Upon submission of such a report, Respondent shall immediately cease the practice of professional counseling and/or addiction counseling. 18. Respondent shall make every effort to ensure that all reports by the practice monitor are complete and timely submitted to the Board and Director. If, in the Board or Director's judgment, the practice monitor fails to perform the function specified by this Order, the Board or Director may require that a new practice monitor assume the responsibilities herein. If for any reason the practice monitor ceases to perform the functions specified in this Order, Respondent shall submit, in writing, a new proposed practice monitor to the Board and Director within 30 days. • • 19. Respondent or the practice monitor may terminate the monitoring relationship upon written notice to the other and to the Board and Director not less than 60 days before the date of termination. The notice shall state the reason for the termination. Respondent shall immediately initiate efforts to obtain another Board and Director -approved practice monitor, who shall conduct her/his monitoring and report to the Board •and Director in accordance with this Order. 20. The period of probation is tolled during any time that Respondent is not practicing in this state, and such period of probation shall resume at such time as Respondent resumes practicing in the State of Colorado in accordance with this Order. 21. 'Credit toward the period of probation will be given only for the period of time during which Respondent is practicing as a professional counselor and/or addiction counselor in Colorado, is being monitored by a practice monitor and is in full compliance with all terms of this Order. 22. If. at the end of the probationary period, Respondent has adhered to all terms and conditions of this Order, Respondent may request termination of probation. Request for termination of probation rnunst be made in writing to the Board and Director, and Respondent is responsible for establishing, to the satisfaction of the Board and Director, that he has satisfied all terms and conditions of probation. CONTINUING EDUCATION 23. During the period of probation, Respondent must successfully complete at least twenty (20) hours of Board and Director -approved professional continuing education courses in the areas of ethics, supervisory responsibilities, and DVOMB standards and rules. Respondent 4 shall obtain Board and Director approval of the courses prior to enrolling in each course. Upon completion of a course, the provider is to mail to the Board and Director a certificate of completion. TERMS AND CONDITIONS 24. Respondent will strictly observe the prohibitions set forth in §12-43-222, C.R.S., and will ensure that he does not engage in any activities that are prohibited and that s/he practices in accordance with the generally accepted standards of practice. 25. Respondent shall not supervise or consult with other mental health providers for the purpose of those persons providing any type of psychotherapy and/or addiction counseling during the term of probation. 26. All expenses incurred or associated with the practice evaluation, therapy evaluation, therapy, practice monitoring, education, or any other requirement necessary to fulfill - . the terms of this Order, `shalt be the sole responsibility of Respondent and not the Board or _, .Director._ _ • 27. 'During the pendency of this Order, Respondent agrees that he will provide permission to and allow his practice monitor, therapy evaluator, or therapist to provide records and information obtained in the normal course of practice monitoring, therapy evaluation, or treatment to the Board and Director if the practice monitor, therapy eyaluator, or therapist determines that Respondent is not practicing professional counseling and/or addiction counseling in accordance with generally accepted standards of practice or has a condition that renders hitn unable to treat clients with skill and safety or that may endanger the health or safety of persons under his care. As part of this Order, Respondent explicitly waives his right to maintain confidentiality of records or information provided to the practice monitor, therapy evaluator, or therapist in the normal course of practice monitoring, therapy evaluation, or treatment if the practice monitor, therapy evaluator, or therapist determines that he is not practicing professional counseling and/or addiction counseling in accordance with generally accepted standards of practice or has a condition that renders him unable to treat clients with skill and safety or that may endanger the health or safety of persons under his care. 28. In the event Respondent relocates at any time during the probationary period, Respondent shall notify the Board and Director of the change of address. within_3O days of the effective date of such change. 29. Respondent is fully aware of and understands the right to receive a formal notice of hearing and charges and to have a formal disciplinary hearing, pursuant to § 12-43-224, C.R.S., and hereby waives those rights. Further, Respondent also acknowledges that this waiver constitutes a waiver of all rights to appeal in this matter. 30. This Order is entered into by Respondent voluntarily and without coercion, after an opportunity to consult with counsel and with full understanding of the legal consequences of this Order and the right to formal hearing on all matters herein. 5 31. The Order entered pursuant to this Stipulation and Final Agency Order shall constitute a Board and Director Order for purposes of §12-43-222, C.R.S., and shall have the same force and effect as an order entered after a formal disciplinary hearing pursuant to § 12-43-224, C.R.S. 32. Respondent acknowledges and agrees that any violation of this Order shall constitute a violation of a lawful Board and Director Order and be grounds for further proceedings pursuant to the Mental Health Practice Act and, if proven, may constitute a basis for further disciplinary action. The pendency of any disciplinary action shall not affect the obligation of Respondent to comply with the terms of this Order, and this Order shall remain operative and in fill force and effect. 33. Respondent shall obey all state and federal laws while this Order is in effect. 34. This Order constitutes the entire agreement between Respondent and the Board and Director. There are no other promises expressed or implied. In the event that any provision of this Order is deemed unenforceable by a court of competent jurisdiction, such provision shall be severed, and the remainder of this Order shall be given full force and effect. 35. This Order shall become effective when accepted and signed on behalf of the Board and Director. 36. This Order shall be admissible as evidence at any hearing held before the Board and Director. 37. This Order shall be a public record in the custody of the Board and Director. AGREED TO AND ACCEPTED BY: AGREED TO AND ORDERED BY: RESPONDENT A71,,, Cc FOR THE COLORADO BOARD OF LICENSED PROFESSIONAL COUNSELORS AND THE DIRECTOR OF THEpIVISION OF REGISTRATIONS ROBERT (CHARLIE) JOHNS E 4I. HINES LPC No. 3108 Program Director CAC III No. 1348 Effective Date: This / day of 6 .2011. ADDICTION COUNSELOR PROGRAM Richard P. Morales, Program Director 1560 Broadway. Suite 1350 Denver, Colorado 80202 Phone (303) 8947768 Fax (303) 894-7764 TTY: Dial 711 for Reiay Colorado w Av.dora.state.co.ushnental-health June 3, 2008 Marcela Paiz VIEMI RE: Anonymous Complaint Case #2008-002348 Letter of Admonition Dear Ms. Paiz: STATE OFtOLORADO Departrnent of Regulatory Agencies D. Roo Munn, Executive Director Division of Registrations Rosemary McCook Director Allied Health Section Shelley Hitt. Section Director Bill Ritter, Jr. Governor At its meeting on May 19, 2008, the Division Director for the Colorado Addition Counselor Program (Division Director), the Division Director reviewed the available material concerning a anonymous complaint filed against you. After thorough review and discussion, the Division Director found probable cause to believe you viola Standards 10.02, 10.03, 10.04 and 10.05 and issued this Letter of Admonition in accordance with CRS 12 Specifically, the Division Director determined: violated DVOMB -43-224(3xd). • You provided domestic violence treatment to female offenders for which you were not approved by the Domestic Violence Offenders Board (DVOMB). By this letter, the Division Director takes the formal disciplinary action of admonishing you for the conduct specified above, and warns you that repetition of such practice may lead to imposition of more severe disciplinary action. This letter open public record and a reportable action to individuals or entities requesting disciplinary information. The Division obligais ti an Director strongly encourages you to review and understand the Mental Health Practice Act requirements and for the practice of addiction counseling/psychotherapy in Colorado. • obligations In accordance with CRS 12-43-224(3)(d), the Division Director advises you that you have the right to make a written request that the Division Director initiate format disci Tinary proceedings in order to adjudicate the conduct or acts upon which this letter is based. You must make your written request within twenty (20) days after receipt of this letter and P address your request to Richard P. Morales, Program Director, at the above letterhead address. If you make a timely request, the Division Director will deem this letter of admonition vacated and may proceed with disciplinary and/or injunctive proceedings in accordance with CRS 12-43-224(3)(d), and applicable rules. If this fetter is not vacated, it will become the final agency action in this matter. Sincerely, cZrituAiA ‘P_ Richard P. Morales Program Director cc: Cheryl Davis, DVOMB G:\Allied Healthcare and Director Programs lMen1Correspondenceled Mtg Corr LetterslCAC120071CAC 2008-8 CORR L0A.doc STATE OF COLORADO ADDICT, ON COUNSELOR PROGRAM Gayle D. Fidler, Program Director 1560 Broa chvay, Suite 1350 Denver, Colorado 80202 Phone (303) 894-7766 Fax (303) 694-7764 TTY: Dial 711 for Relay Colorado vwvw.dora. state.co.usknental-health October 31, 2007 Ma la M Paiz RE: Anonymous Complaint Case #2006-003190 & 2007-002615 Letter of Admonition Dear Ms. Paiz: Department of Regulatory Agencies D. Rico Munn. Executive Director Division of Registrations Rosemary McCool, Director Allied Health Section Shelley Hitt, Section Director Bill Ritter, Jr. Govemor At its meeting on September 26, 2007, the Division Director for the Colorado Addition Counselor Program (Division Director), the Division Director reviewed the available material concerning the anonymous complaint ant. After thorough review and discussion, the Division Director found probable cause to believe you violated CRS 12-43- 222(1)(g), and issued this Letter of Admonition in accordance with CRS 12-43-224(3)(d). Specifically, the Division Director determined: • You violated generally excepted standards and DVOMB standards with regards to therapy group size. By this letter, the Division Director takes the formal disciplinary action of admonishing you for the conduct specified above, and warns you that repetition of such practice may lead to imposition of more severe disciplinary action. This letter is an open public record and a reportable action to individuals or entities requesting disciplinary information. The Division Director strongly encourages you to review and understand the Mental Health Practice Act requirements and obligations for the practice of addiction counseling/psychotherapy in Colorado. In accordance with CRS 12-43-224(3)(d), the Division Director advises you that you have the right to make a written request that the Division Director initiate formal disciplinary proceedings in order to adjudicate the conduct or acts upon which this letter is based. You must make your written request within twenty (20) days after receipt of this letter and address your request to Gayle D. Fidler, Program Director, at the above letterhead address. If you make a timely request, the Division Director will deem this letter of admonition vacated and may proceed with disciplinary and/or injunctive proceedings in accordance with CRS 12-43-224(3)(d), and applicable rules. If this letter is not vacated, it will become the final agency action in this matter. Sincerely, �4, Hsu.. Gayle D. Idler Program Director cc: Cheryl Davis, DVOMB G:1Allied Healthcare and Director Programs1MenlCorrespondencel td Mtg Corr LetterslCAC120071CAC 2007-11 CORR LOA.doc OF Cozo ~� Q .SY� o :*e (.7.7,3);`R \<,, .,. 1876 •s John W. Hickenlooper Governor Barbara J. Kelley Executive Director Department of Regulatory Agencies June 21, 2011 Marcela Paiz, CAC III Division of Registrations Mental Health Programs Rosemary McCool Ronne M. Hines Director Program Director MAILED CERTIFIED MAIL RE: Complaint Filed By DVOMB Case #2011-000003 (CAC) Letter of Admonition Dear Ms. Paiz: On June 7, 2011, the Division Director for the Office of Addiction Counselors ("Director") reviewed the available material concerning the above referenced case. After thorough review, the Director found probable cause to believe you violated CRS 12-43-216, 12-43-222(1) (g), (m), and, (n) and issued this Letter of Admonition in accordance with CRS 12-43-224(3)(d). Specifically, the Director determined: • You were removed from the DVOMB Provider List effective March 29, 2010. • You violated DVOMB standards 5.01 and statute 16-11.8-104 CRS by continuing to conduct domestic violence offender treatment groups after March 29, 2010. • You violated DVOMB standards 5.01 and statute 16-11.8-104 CRS by allowing non -approved DVOMB individual to provide domestic violence offender treatment. By this letter, the Director takes the formal disciplinary action of admonishing you for the conduct specified above, and warns you that repetition of such practice may lead to imposition of more severe disciplinary action. This letter is an open public record and a reportable action to individuals or entities requesting disciplinary information. The Director strongly encourages you to review and understand the Mental Health Practice Act requirements and obligations for the practice of addiction counseling/psychotherapy in Colorado. In accordance with CRS 12-43-224(3)(d), the Director advises you that you have the right to make a written request that the Director initiate formal disciplinary proceedings in order to adjudicate the conduct or acts upon which this letter is based. You must make your written request within twenty (20) days after receipt of this letter and address your request to Ronne M. Hines, Program Director, at the address listed below. If you make a timely request, the Director will deem this letter of admonition vacated and may proceed with disciplinary and/or injunctive proceedings in accordance with CRS 12-43-224(3)(d), and applicable rules. If this letter is not vacated, it will become the final agency action in this matter. Sincerely, THE OFFICE OF ADDICTION COUNSELORS e M. - i es Program Director R,NtH/vm 1560 Broadway, Suite 1350 Denver, Colorado 80202 Phone 303.894.7800 Fax 303.894.7764 www.dora.state.co.us V/TDD 711 Consumer Protection . J Case Information Page I of 2 Living in Denver A -Z Departments and Sery Doing Business in Denver City Government Denver County Court Record Search County Court Home Page County Court Search Page This case is Closed. Case Number: 98GS131517 Case Information Status: Case Type: Violation Date: Date Filed: Courtroom: Domestic Violence: CLOSE 08/15/1998 YES Pay Amount: $0.00 Location: AB Number: GO Number: Party Information Party Type Last Name First Name DEFENDANT VILLA-GARCIA ARTURO Race Hair HISPANIC BROWN Attorney Number Attorney Name Violation Information Violations Description Points 38-93 ASSAULT Action Information Date Action 05/11/2002 00:00 (CNV) PROBATION CONVERSION 01/01/2000 00:00 CNV SENTENCE GROUP Minutes 08-17-98.CONDITIONAL SUSPENDED SENTENCE 200 DAY(S). 08-17-98.CREDIT TIME SERVED 4 DAY(S). 11-20-98.CREDIT TIME SERVED 50.00 08-17-98.JAIL IMPOSED 204 DAY(S). COURTRM/12T. 08-17-98.PROBATION GRANTED 1 YEAR(S). 06-16-99.PROBATION TERMINATED COURTRM/12T. 10-05-98.STAY OF EXECUTION 129.00 08-17-98.SUPERVISED SENTENCE 01/01/2000 00:00 CNV FINE GROUP Minutes 08-17-98.COURT COSTS IMPOSED $ 18.00 11-20-98.COURT COSTS PAID $ 18.00 10-07-98.FAILURE TO PAY FINE OR COST $ 10-07-98.MITTIMUS FEE IMPOSED $ 25.00 MI Suffix Weight Height 160 510 Disposition Judicial Officer http://www.denvergov.org/apps/NewCourt/name_search.aspx 10/13/2011 Case Information Page 2 of 2 Minutes 11-20-98.MITTIMUS FEE PAID 25.00 08-17-98 VICTIM ASSISTANCE SURCHARGE $ 11.00 11-20-98.VICTIM ASSISTANCE SURCHARGE PAID $ 11.00 08-17-98.PROBATION COSTS IMPOSED $ 100.00 11-20-98.PROBATION COSTS PAID $ 50.00 09/09/1999 00:00 DEAD JACKET 06/15/1999 00:00 CNV GENERAL SESSIONS 11/19/1998 00:00 DEFENDANT JAILED 11/19/1998 00:00 CNV MITT VACATED 10/07/1998 00:00 FAIL TO PAY WARRANT ORD 08/17/199813:30 ARRAIGNMENT 08/17/1998 00:00 DEFENDANT JAILED 08/17/1998 00:00 CNV FINAL DISPOSITION 08/17/1998 00:00 CNV GUILTY PLEA Copyright ® 2010 City of Denver I Privacy Statement I Terms of Use I A-2 Departments and Services I Sign Ui http://www.denvergov.org/apps/NewCourt/name_search.aspx 10/13/2011 Case Information Page 1 of 2 Living in Denver A -Z Departments and Sery Doing Business in Denver City Government Denver County Court Record Search County Court Home Page County Court Search Page Case has been Closed Case Number: 92C381411 Case Information Status: Case Type: Violation Date: Date Filed: Courtroom: CLOSE ASSAULT 10/17/1992 11/09/1992 00:00316R Pay Amount: $0.00 Location: AB Number: GO Number: Party Information Party Type Last Name First Name MI Suffix DEFENDANT VILLA ARTURO Race Hair Weight Height Attorney Number Attorney Name Violation Information Violations Description Points Disposition 18-3-204 Action Information Date Action Judicial Officer Crtrm Dispo 11/19/1997 00:03 BOND INFO -GGCC ("D" LINE) Minutes BDATE= 11/08/92 BOND#=503259 BTYPE=S BAMT= 1000.00 BSTATUS=POS PRTY=1 11/19/1997 00:02 SENTENCE - GGCC (" I " LINE) Minutes JDATE=11/22/93 ORDR=PRJL JAIL=00 PROB/UPS=02Y FINE=0 CC=148.00 SOEDT=11/30/93 PF 360D IMPOSED, 300D SUSPENDED, SERVE 60D IHD 4-6-94 NO FURTHER REVWS 11/19/1997 00:01 PAYMENT - GGCC ("Z" LINE) Minutes PDATE=12/07/93 CODE=FD REC#=352 NAME=SAME PIF AMT DUE=0 AMT -PAID= 148.00 04/06/1994 09:00 REVIEW DATE 316R 11/22/1993 09:00 JURY TRIAL 316R SENTENCE 09/17/1993 09:00 RETURN ON PSI 316R SET NEW C 08/19/1993 08:30 RETURN ON PSI 316R SET NEW C 07/14/1993 08:30 RETURN ON PSI 316R SET NEW C 05/27/1993 09:30 PLEA AND SETTING HEARING 316R GUILTY PLE http://www.denvergov.org/apps/NewCourt/name_search.aspx 10/13/2011 Case Information • Page 2 of 2 - 05/05/1993 08:30 04/13/1993 08:30 02/26/1993 08:30 12/28/1992 08:30 12/08/1992 08:30 PLEA AND SETTING HEARING PLEA AND SETTING HEARING PLEA AND SETTING HEARING PLEA AND SETTING HEARING ARRAIGNMENT 316R SET NEW COUF 316R SET NEW COUF 316R SET NEW COUF 316R SET NEW COUF 122C SET NEW COUF Copyright © 2010 City of Denver I Privacy Statement I Terms of Use I A -Z Departments and Services I Sign U. http://www.denvergov.org/apps/NewCourt/name_search.aspx 10/13/2011 EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide Domestic Violence Intervention, Mental Health Services, Monitored Sobriety Services, and Substance Abuse Treatment, as referred by the Department. 2. Contractor will utilize the following in the delivery of service: a. DV Evaluation and Treatment i. Contractor will conduct service per DVOMB standards, and services will be provided by a DVOMB provider. b. Substance Use Disorder Evaluation and Treatment c. DUI Education and Treatment d. Anger Management e. Adult Responsibility f. Victim Empathy g. Parenting h. Life Skills 3. Capacity for Services: Intensive Outpatient (IOP) — 9+ hours per week. 4. Goals of Service: To identify, and address risks and need of the client and increase skills for relationships and parenting. 5. Outcomes of Services: Reduction or elimination of harm to self or others, recovery work in victim empathy, accountability in safe and secure relationships. 6. Target Population: a. Ages 14 to 99 years old b. Male and female (treatment is gender specific) c. LGBTQ services offered 7. Language: English and Spanish. All languages accepted with translator. 8. Service Access: a. In-office/in-person b. 14311 East 4th Avenue, Aurora, CO 80011 c. 83 North 4th Avenue, Brighton, CO 80601 d. 9051 Washington Street, Thornton, CO 80229 9. 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. 10. 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 (hainlejd@weldgov.com, 970-400-6210). 1 11. 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 (hainlejd@weldgov.com, 970-400-6210). 12. 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 (hainlejd@weldgov.com) immediately via email, to discuss service continuation. 13. 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. 14. 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. 15. 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. 16. 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. 17. 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. Contractor may participate by phone, if approved by the Department. 18. 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 2 The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 3 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, 2020. 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 Domestic Violence Intervention: $125.00/Episode (Anger Management Evaluation) $35.00/Episode (Domestic Violence Group, 2 hours/episode) $80.00/Episode (Domestic Violence Intake Evaluation) Mental Health Services: $30.00/Episode (Adolescent Group Therapy, 2 hours/episode) $45.00/Hour (Adolescent Individual Therapy) $80.00/Hour (EMDR Therapy) $65.00/Hour (Family Therapy) $65.00/Hour (Individual Therapy) $35.00/Episode (Standard Group Therapy, 2 hours/episode) Monitored Sobriety Services: $17.00/Test (7 Panel Urinalysis) $10.00/Test (Breathalyzer) $75.00/Test (Hair Test) $165.00/Test (Steroid Urinalysis) $25.00/Test (Swab Test) Substance Abuse Treatment: $150.00/Episode (Substance Abuse Evaluation) $50.00/Episode (Substance Abuse Intake Assessment) 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. Hello