HomeMy WebLinkAbout20172866.tiff6r6 -0.d. I D k 1811
AGREEMENT AMENDMENT
BETWEEN
THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND MILESTONES COUNSELING SERVICES, LLC
This Agreement Amendment, made and entered into o 1e ay of
2018 by and
between the Board of Weld County Commissioners, on behalf of the Weld Co(xhty Dipartment of Human
Services, hereinafter referred to as the "Department", and Milestones Counseling Services, LLC, hereinafter
referred to as the "Contractor".
WHEREAS the parties entered into an Agreement for Foster Parent Consultation (the "Original
Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No.
2017-2866 approved on August 21, 2017.
WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with
the terms of the Original Agreement, 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, 2018.
• The Amendment, together with the Original Agreement, constitutes the entire understanding
between the parties. The following change is hereby made to the Agreement:
1. WHEREAS, the Colorado Department of Human Services has provided Core Services or other funds
to the Department for Foster Parent Consultation.
2. Paragraph 1, Term
This agreement shall become effective on June 1, 2017, upon proper execution of this Agreement
and shall expire May 31, 2019, unless sooner terminated as provided herein.
3. Payment
The Department and the Contractor agree that all benefits from private insurance and/or other
funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's
Compensation must be exhausted before Core Services or other Department funds can be accessed
for services. Exceptions to this Paragraph may include, if approved by the Department, the
following:
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;
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v. Medicaid is exhausted for the needed service; or
vi. Medicaid denied service.
vii. The client is not eligible for Medicaid.
4. Exhibit C, Scope of Services, amended as attached.
5. Exhibit D, Payment Schedule, 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.
COUNTY:
ATTEST: O:0;(di
Weld 'ou ty Clerk to the Board
By:
Deputy Clerk the oard
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
eve Moreno, Chair JUL 2 3 2018
CONTRACTOR:
Milestones Counseling Services, LLC
832 West Eisenhower Boulevard, Suite C
Loveland, Colorado 80537
(970) 403-7653
By:
Addie Campbell, Therapist
Date: 57 3 //2o' /'
O10/% c2 e
EXHIBIT C
SCOPE OF SERVICES
1. Contractor will provide Foster Parent Consultation services to children, youth and families, as referred by the
Department.
2. Foster Parent Consultation:
a. Contractor will work collaboratively with children, foster parents, caseworkers, foster care
coordinators and other service providers to identify and address issues, in a solution -focused manner
that could potentially disrupt placements.
b. Contractor will assess foster families abilities and capacity on an ongoing basis to appropriately care
for the foster children in their home and report this information on a monthly basis to the
Department.
c. Contractor will conduct services in the following manner:
i. Contractor will meet with the foster home parent(s) to gather information regarding their
specific concerns and prior attempts to meet the child's specific needs.
ii. Contractor will provide parents with the Parenting Relationship Questionnaire (PRQ). The
PRQ takes 10-15 minutes to complete and is used to assess different parenting
relationships, beliefs, and practices among parents and/or caregivers. It is appropriate for
the assessment of parents or caregivers of children aged two (2) to 18. The PRQ measures
caregivers' level of stress or distress in parenting, parenting confidence, involvement,
discipline practices and communication.
iii. Contractor will meet with the foster child, if age appropriate, to gather information about
any concerns or barriers to maintaining the placement.
iv. Contractor will observe foster child and parents to gather additional information on
parenting style, barriers to the formation of the parent/child relationship, possible "hot
spots", and to develop an intervention plan.
v. Contractor will meet with foster child and parents to provide feedback following
implementation of the intervention plan to assess progress.
vi. Contractor will administer the PRQ again at the conclusion of services to measure the level
of change.
vii. Contractor can conduct additional sessions/follow-up if approved by the Department.
d. Contractor will conduct services in the following manner:
i. Contractor will obtain pertinent information from the caseworker.
ii. Contractor will meet with the family and conduct a life skills assessment to identify
deficiencies and set goals.
iii. Contractor will provide education, concrete lessons and will model concepts as a means of
teaching skills and working towards goals.
3. Contractor can provide bilingual services (Spanish).
4. 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.
5. 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.
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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
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.
9. Contractor will offer an initial appointment within seven (7) days of receiving the referral and will make at
least three (3) attempts to contact the client and set up services. The first attempt will occur within 24
hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to
engage client in referred services. If after three (3) attempts the client does not respond the Contractor will
notify the caseworker and the Child Welfare Contract and Services Coordinator immediately.
10. Contractor understands that the Department will not reimburse Contractor for "no shows" or cancelled
appointments, either on the part of the client or the Contractor.
11. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings
include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings.
The Department will reimburse for actual participation in the meeting only so long as the meeting is at least
one hour in length, participation in the meeting is deemed appropriate and necessary by the Department,
and the Contractor obtains the Facilitator's signature on the Client Verification Form at the time of the
meeting. Staffings and/or meetings other than those listed above are not considered reimbursable unless
otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may appear by
phone.
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EXHIBIT D
PAYMENT 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 specified 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 in Trails after May 31,
2018.
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
Foster Parent Consultation:
$100.00/Hour (Foster Parent Consultation)
$80.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting)
Mileage shall be reimbursed after the first 30 miles at two cents below the most current IRS rate/mile.
Contractor may not attempt to collect co -pays and/or fees for services for which a Department client is
responsible, but which a particular client refuses or fails to pay.
Contractor will collect any applicable sliding scale co -pays and credit the Department for any payment
received on the monthly billing.
3. Submittal of Vouchers
Contractor shall prepare and submit monthly an itemized voucher, and signed monthly report if
applicable, certifying that services authorized were provided on the date(s) indicated and the charges
made were pursuant to the terms and conditions of Paragraph 3 and Exhibit A.
Contractor shall submit all monthly billings and applicable reports to the Department by the 7th day of the
month following the month the cost was incurred. Failure to submit by the aforementioned deadline may
result in forfeiture of payment.
a. 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.
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b. For one-time services, proof of services rendered shall be receipt of the completed product.
c. For Monitored Sobriety services, proof of services rendered shall be the test result.
ANA
PRODUCER IBRANCH
018098 970
Named Insured
HEALTHCARE PROVIDERS SERVICE
ORGANIZATION PURCHASING GROUP
Certificate of 3{nfiurattce ®HPSO
Healthcare Pnwi,4r, Service Omeniwdon—
PREFIX
HPG
OCCURRENCE POLICY FORM Print Date: 09/15/17
POLICY NUMBER
0299197210-8
Adelaida Campbell
904 49th Avenue Ct
Greeley, CO 80634-1912
Medical Specialty
Code
Licensed Professional Counselor
Excludes Cosmetic Procedures
Professional Liability
Your professional liability limits shown above include the following:
• Good Samaritan Liability • Malplacement Liability • Personal Injury Liability
• Sexual Misconduct included in the PL Limit shown above subject to $25,000 aggregate sublimit
80723
Policy Period:
From 09/14/17 to 09/14/18 at 12:01 AM Standard Time
Program Administered by:
Healthcare Providers Service Organization
159 E. County Line Road
Hatboro, PA 19040-1218
1-800-982-9491
www.hpso.com/renew
Insurance is provided by:
American Casualty Company of Reading, Pennsylvania
333 South Wabash Avenue Chicago, Illinois 60604
$1,000,000 each claim $5,000,000 aggregate
Coverage Extensions
License Protection
Defendant Expense Benefit
Deposition Representation
Assault
Includes Workplace Violence Counseling
Medical Payments
First Aid
Damage to Property of Others
Information Privacy (HIPAA) Fines & Penalties
General Liability
25,000
1,000
10,000
25,000
25,000
10,000
10,000
25,000
per proceeding
per day limit
per deposition
per incident
per person
per incident
per incident
per incident
$ 25,000 aggregate
$ 25,000 aggregate
$ 10,000 aggregate
$ 25,000 aggregate
$ 100,000 aggregate
$ 10,000 aggregate
$ 10,000 aggregate
$ 25,000 aggregate
General Liability
Fire and Water Legal Liability
Personal Liability
Total: $317.00
1,000,000 each claim / 1,000,000 aggregate
Included in the GL limit above subject to $250,000 aggregate sublimit
$1,000,000 aggregate
Premium reflects self-employed, part-time rate.
Policy Forms & Endorsements (Please see attached list for a general description of many common policy forms and endorsements.)
G -121500-D G -121501-C CNA82011 G -145184-A G -147292-A CNA81753 CNA81758 GSL13424 GSL15563 GSL15564
GSL15565 GSL17101 CNA80052 CNA80051 G -123846-005 G -121504-C G -121487-B CNA79575
ISP-AA/tA 711)1`.4
Secretary
Keep this Certificate of Insurance in a safe place. This Certificate of Insurance and proof of payment are your proof of coverage.
There is no coverage in force unless the premium is paid in full. In order to activate your coverage, please remit premium in full by
the effective date of this Certificate of Insurance.
Form #: G -141241-B (3/2010)
Master Policy: 188711433
HPS0-250-R-CON-H1 20170915-005
POLICY FORMS & ENDORSEMENTS
The following are the policy forms and endorsements that apply to your current professional liability insurance policy.
COMMON POLICY FORMS & ENDORSEMENTS
FORM #
G -121500-D
G -121501-C
CNA82011
G -145184-A
G -147292-A
CNA81753
CNA81758
GSL13424
GSL15563
GSL15564
GSL15565
GSL17101
CNA80052
CNA80051
G -123846-005
General
G -121487-B
CNA79575
DESCRIPTION
Common Policy Conditions
Occurrence Policy Form
Healthcare Providers Related Claims Endorsement
Policyholder Notice - OFAC Compliance Notice
Policyholder Notice - Silica Mold & Asbestos Disclosure
Cap on Losses from Certified Acts of Terrorism
Offer of Terrorism Coverage - Disclosure of Premium
Services to Animals
Information Privacy Coverage Endorsement HIPAA Fines Penalties & Notification Costs
Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion
Healthcare Providers Professional Liability Assault Coverage
Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies
Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement
Amended Definition of Personal Injury Endorsement
Colorado Cancellation and Non -Renewal
Liability Form
Amendment to Certificate
Exclusion of Cosmetic Procedures
OPTIONAL ENDORSEMENTS
FORM #
G -121504-C
DESCRIPTION
General Liability Form
Self-employed individuals may be eligible for General Liability coverage subject to underwriting approval. Should an individual practitioner's status
change from self-employed to employed, general liability coverage will be deleted and replaced with workplace liability. Please contact Healthcare
Providers Service Organization for details.
Form #: G -141241-B Named Insured: Adelaida Campbell
Master Policy #: 188711433 Policy #: 0299197210-8
H10412
/z
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND MILESTONES COUNSELING SERVICES
This Agreement, made and entered into thday of , 2017, by and between the Board of Weld
County Commissioners, on behalf of the Weld County Department of man Services, hereinafter referred to as
the "Department' and Milestones Counseling Services, hereinafter ref rred 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 Proposal,
Exhibit C, Scope of Services, and Exhibit D, Payment Schedule. Each of these documents is attached hereto and
incorporated herein by this reference.
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 funding to the
Department for Foster Parent Consultation.
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, 2017, upon proper execution of this Agreement and
shall expire May 31, 2018, 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 Department's Resource Manager, Child Welfare Contract and Services Coordinator, or
through a Team Decision Making (TDM) meeting or Family Team Meeting (FTM). No other
Department staff or other party to the case may authorize services or modifications to services.
c. Contractor agrees to submit an itemized complete billing statement by the 7th of the month,
following the month of service, utilizing billing forms required by the Department.
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syd,///i
2017-2866
,CC -/2o08."
d. Contractor agrees to submit a monthly report with the billing statement by the 7th of the month
following the month of service for each client receiving ongoing services. One-time services will be
verified through receipt of the completed product (ex. psychological evaluation, substance abuse
evaluation). Verification of Monitored Sobriety Services will be the test result.
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.
Monthly reports will be submitted through the Department's online reporting system, unless
otherwise directed or agreed to by the Department.
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.
b. Payment shall be made in accordance with Exhibit A, Weld County's Request for Proposal, Exhibit
B, Contractor's Proposal, Exhibit C, Scope of Services, and Exhibit D, Payment Schedule, attached
hereto and incorporated herein by reference, so long as services are rendered satisfactorily and in
accordance with the Agreement.
c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent
upon, the continuing availability of said funds for the purposes hereof.
d. The Department may withhold reimbursement if Contractor has failed to comply with any part of
the Agreement, including the Financial Management requirements, program objectives, contractual
terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may
appeal such circumstance in writing to the Director of Human Services. The decision of the Director
of Human Services shall be final.
5. Financial Management
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,
Payment 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 ACH Form for Colorado Providers, which will be
provided by the Department. Contractor is solely responsible to submit the ACH Form to the State of
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Colorado per the directions on the form. Failure to complete and submit this form in a timely and
accurate manner may result in a delay of payment.
c. Contractor agrees to accept payment through county warrant when funding source does not
allow for direct deposit.
7. Compliance with Applicable Laws
a. At all times during the performance of this Agreement, Contractor will strictly adhere to all
applicable Federal and State laws, order, and applicable standards, regulations, interpretations
and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all
applicant/recipient records, papers, documents, tapes and any other materials that have been or may
hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws
and regulations, including, but not limited to the following:
- Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil
Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45
C.F.R. Part 80 et. seq.; and
- all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of
race, creed, color, sex, or national origin, be excluded from participation in, be denied the
benefits of, or be otherwise subjected to discrimination under the approved Agreement.
- Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its
implementing regulations, 45 C.F.R. Part 84; and
- the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its
implementation regulations, 45 C.F.R. Part 91; and
- Title VII of the Civil Rights Act of 1964; and
- the Age Discrimination in Employment Act of 1967; and
- the Equal Pay Act of 1963; and
- the Education Amendments of 1972; and
- Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and
- all regulations applicable to these laws prohibiting discrimination because of race, color,
national origin, sex, religion, and handicap, including Acquired Immune Deficiency Syndrome
(AIDS) or AIDS related conditions covered under Section 504 of the 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.
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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 Core Services.
d. Contractor assures and certifies that it and its principals:
- Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from covered transaction by a Federal or State department or agency;
and
- have not, within a three-year period preceding this Agreement, been convicted of or
had a civil judgment rendered against them for commission of fraud or criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State or
Local) transaction or contract under public transaction; violation of federal or state antitrust
statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction
of records, making false statements, or receiving stolen property; and
- are not presently indicted for or otherwise criminally or civilly charged by a government
entity (federal, state or local) with commission of any of the offenses enumerated in this
certification; and
- have not, within a three-year period preceding this Agreement, had one or more public
transactions (federal, state, or local) terminated for cause or default.
e. Public Contracts for Services C.R.S. §8-17.5-101. Contract Professional certifies, warrants, and
agrees that it does not knowingly employ or contract with an illegal alien who will perform work under
this contract. Contract Professional 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). Contract Professional 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 Contract Professional that the subcontractor shall not knowingly employ or contract with an illegal
alien to perform work under this Agreement. Contract Professional 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 Contract Professional obtains actual knowledge that a
subcontractor performing work under the public contract for services knowingly employs or contracts
with an illegal alien Contract Professional shall notify the subcontractor and County within three (3)
days that Contract Professional 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. Contract Professional 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. Contract
Professional 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 Contract
Professional participates in the State of Colorado program, Contract Professional shall, within twenty
days after hiring a new employee to perform work under the contract, affirm that Contract Professional
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. Contract Professional shall deliver
to County, 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 Contract
Professional fails to comply with any requirement of this provision or of C.R.S. §8-17.5-101 et seq.,
County, may terminate this Agreement for breach, and if so terminated, Contract Professional 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
Contract Professional receives federal or state funds under the contract, Contract Professional 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 Contract Professional operates as a sole proprietor, it hereby swears
or affirms under penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully
present in the United States pursuant to federal law, (b) shall produce one of the forms of
identification required by C.R.S. § 24-76.5-101, et seq., and (c) shall produce one of the forms of
identification required by C.R.S. § 24-76.5-103 prior to the effective date of the contract.
8. Compliance with Child and Family Services Review
The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas;
Safety, Permanency and Well Being of families. For each outcome, data and performance indicators
measure each state's performance according to national standards and monitor progress over time.
Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance
services to families.
Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well
Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under
this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under
the Child and Family Services Review (CFSR), and will address the aforementioned three areas when
completing monthly reports as required by Paragraph 3(d) of this Agreement.
9. Insurance Requirements
Contractor and 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/Contract Professionals 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/Contract
Professionals shall keep the required insurance coverage in force at all times during the term of
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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, County must be notified by the Contractor/Contract
Professional. Contractor/Contract Professional shall be responsible for the payment of any
deductible or self -insured retention. County reserves the right to require Contractor/Contract
Professional to provide a bond, at no cost to County, 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/Contract Professional. Contractor/Contract Professional 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/Contract Professional 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 Contract Professional's employees acting within
the course and scope of their employment. If Contractor is an Independent Contractor,
as defined by the Colorado Worker's Compensation Act, this requirement shall not apply.
Contractor must submit to the Department a Declaration of Independent Contractor
Status Form prior to the start of this agreement.
ii.Commercial General Liability Insurance written on ISO occurrence form CG 00 01 10/93
or equivalent, covering premises operations, fire damage, independent Contractors,
products and completed operations, blanket contractual liability, personal injury, and
advertising liability with minimum limits as follows:
- $1,000,000 each occurrence;
- $2,000,000 general aggregate;
- $50,000 any one fire; and
- $500,000 errors and omissions.
iii.Automobile Liability: Contractor/Contract Professional 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 reduce by twenty-five percent (25%) or more
by paid or reserved claims, Contractor shall notify County 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 County.
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 County, whichever is earlier.
c. Contractors/Contract Professionals 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/Contract Professional shall provide a copy of this
information to its insurance agent or broker, and shall have its agent or broker provide proof of
Contractor/Contract Professional's required insurance. County reserves the right to require
Contractor/Contract Professional 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/Contract Professional's insurer shall name County as
an additional insured as follows:
County of Weld
1150 '0' Street
Greeley, Colorado 80631
f. Waiver of Subrogation: For all coverages, Contractor/Contract Professional's insurer
shall waive subrogation rights against County.
g. Subcontractors: All subcontractors, 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/Contract Professional. Contractor/Contract Professional 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/Contract Professional agrees to provide proof of insurance for all such subcontractors,
independent contractors, sub -vendors suppliers or other entities upon request by the County.
A provider of Professional Services (as defined in the Bid or RFP) shall provide the following
coverage:
Professional Liability: Contract Professional shall maintain limits of $1,000,000 for each claim, and
$2,000,000 aggregate limit for all claims.
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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 that 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 970-352-1551, x6503, 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 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. As the
monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special
analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such
monitoring shall be performed in a manner that will not unduly interfere with 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.
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- 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, Administrator Addie Campbell, Therapist
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) 352-1551
18. Litigation
For Contractor:
Addie Campbell, Therapist
832 West Eisenhower Boulevard, Suite C
Loveland, CO 80537
(970) 403-7653
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.
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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
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.
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,
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to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and
evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The
results of the monitoring and evaluation activities shall be provided to the appropriate and interested
parties.
All such records, documents, communications, and other materials created pursuant or related to this
Agreement shall be maintained by the Contractor in a central location and shall be made available to the
Department upon its request, for a period of seven (7) years from the date of final payment under this
Agreement, or for such further period as may be necessary to resolve any matters which may be pending,
or until an audit has been completed with the following qualifications: If an audit by or on behalf of the
Federal and/or State government has begun but is not completed at the end of the seven (7) year period,
or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until
the resolution of the audit finding.
25. Confidentiality of Records
Contractor shall protect the confidentiality of all applicant records and other materials that are
maintained in accordance with this Agreement except for purposes directly connected with the
administration of Child Protection. No information about or obtained from any applicant/recipient in
possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minor's
parent or guardian unless in accordance with the Contractor's written policy governing access to,
duplication and dissemination of, all such information, in any form, including social networks. Contractor
shall advise its employees, agents, and subcontractor, if any, that they are subject to these confidentiality
requirements.
Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written
explanation of these confidentiality requirements before access to confidential data is permitted.
Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality
agreement and shall provide a copy of such agreement to the Department, if requested.
26. 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
Contract Professional agrees that it is an independent Contract Professional and that Contract
Professional'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. Contract Professional shall
perform its duties hereunder as an independent Contract Professional. Contract Professional shall be
solely responsible for its acts and those of its agents and employees for all acts performed pursuant to
this Agreement. Contract Professional, 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 Contract Professional or any of its agents or employees. Unemployment
insurance benefits will be available to Contract Professional and its employees and agents only if such
11
coverage is made available by Contract Professional or a third party. Contract Professional shall pay when
due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred
pursuant to this Agreement. Contract Professional shall not have authorization, express or implied, to
bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement.
Contract Professional 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,
and 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.
31. Acceptance of Services Not a Waiver
Upon completion of the work, the Contractor shall submit to Department originals of all tests and results,
reports, etc., generated during completion of this work. Acceptance by 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 conflict with or in any way appear to conflict with the full performance of its
12
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
Contract Professional'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, Contract Professional agrees that the Weld County District Court shall have exclusive
jurisdiction to resolve said dispute.
35. Subcontractors
Contract Professional acknowledges that County has entered into this Agreement in reliance upon the
particular reputation and expertise of Contract Professional. Contract Professional shall not enter into any
subcontractor agreements for the completion of this project without County's prior written consent, which
may be withheld in County's sole discretion.
36. Attorneys Fees/Legal Costs
In the event of a dispute between County and Contract Professional, 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 Contract Professional under this Agreement or individual work order
shall become or remain (as applicable), the property of County. In addition, all reports, documents, data,
plans, drawings, records and computer files generated by Contract Professional 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 County. Contract Professional shall not make use of such
material for purposes other than in connection with this Agreement without prior written approval of
County.
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
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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: dia.& M• e.doitA, BOARD OF COUNTY COMMISSIONERS
Weld C n Clerk to the Board WELD COUNTY, COLORADO
By:
Deputy Clerk to t Bo
15
Julie ozad, Chair
CONTRACTOR:
AUG
2017
Milestones Counseling Services
832 West Eisenhower Boulevard, Suite C
Loveland, Colorado 80537
(970) 403-7653
By:
Date:
4lc
rrim/
Addie Campbell, Therapist
EXHIBIT A
WELD COUNTY'S REQUEST FOR PROPOSAL
REQUEST FOR BIDS AND PROPOSALS
WELD COUNTY, COLORADO
1150 O STREET
GREELEY, CO 80634
DATE: April 3, 2017
BID NUMBER: B1700080
DESCRIPTION: Annual Request for Various Services
DEPARTMENT: Human Services
MANDATORY PRE -BID CONFERENCE DATE: N/A
BID OPENING DATE: APRIL 24, 2017
PAGES 1-9 OF THIS DOCUMENT CONTAINS GENERAL INFORMATION. NOT ALL OF THE INFORMATION
CONTAINED IN PAGES 1-9 MAY BE APPLICABLE. THE SCOPE OF WORK AND SPECIFICATIONS UNIQUE TO
THIS REQUEST FOR BID FOLLOW PAGE 9.
I. NOTICE TO BIDDERS
A. The Families, Youth and Children's Commission, on behalf of the Weld County Department of
Human Services, by and through the Board of Weld County Commissioners, wishes to purchase the
following:
VARIOUS ENGLISH AND BILINGUAL (ENGLISH/SPANISH) SERVICES (SERVICE AREAS INCLUDED IN THIS
PROPOSAL INCLUDE, BUT ARE NOT LIMITED TO THE BELOW LIST. OTHER SERVICES WILL BE
CONSIDERED AND BIDDERS ARE ENCOURAGED TO SUBMIT FOR UNIQUE AND CREATIVE SERVICES.)
Aftercare Services
Services provided to prepare a childfor reunification with his/her family or
other permanent placement and to prevent future out- of -home placement
of the child.
Anger
Management/Domestic
Violence
Diagnostic and/or therapeutic services to assist in the development of the
family services plan, to assess and/or improve familycommunication,
functioning and relationships, and to prevent further domesticviolence.
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Crisis Intervention and
Stabilization Services
Services that provide an immediate, in- person/in- home response to
families, youth and children, in
*crisis, 24 hours a day, seven (7) days a week.
*A "crisis" is further defined as a situation or circumstance, usually acute
(recent) in nature, which breaks down the normal functioning of an
individual and/or family, and results in the inability of the individual and/or
family to resolve the crisis through normal coping behaviors, orwithout
Day Treatment
Comprehensive, highly structured services that provide education to children
and therapy to children and theirfamilies.
Foster ParentConsultation
Services provided to foster and group home families caring for Weld
County children and youth in their homes to enhance and improve the
quality of care being provided.
Foster ParentTraining
Core training for new Weld County foster parents.
Functional Family Therapy
Intensive family -based treatment that addresses the pervasive patterns of
relational dysfunction known to be determinants of conduct disorder, violent
acting out, and substance abuse among youth 10-18 years old.
Home -Based Intervention
Services provided primarily in the home of the client that include a variety of
services which can include therapeutic services, concrete services, collateral
services and *crisis intervention directed to meet the needs of the child and
family.
*Crisis Intervention is defined as 24/7 phone access and in -home
counseling.
Kinship Services
(Therapeutic)
Kinship services in the areas of (1) consultation and kinship parent support
specific to a child placed in a kinship home, (2) corrective consultation specific
to a child placed in a kinship home, and (3) critical care consultation specific
to a child placed in a kinship home. Children placed in kinship care are
maintained in the lowest level of care and least restrictive setting when out -
of -home placement is necessary.
Life Skills
Visitation (both in -home and in -office) and services provided primarily in the
home that teach household management, effective accessto community
resources, parenting techniques and family conflict management.
Mediation/Intensive Family
Therapy
Therapeutic intervention typically with all family members to improve
family communication, functioning and relationships.
2
Mental Health Services
Diagnostic and/or therapeutic services to assist in the development of
family services plan, to assess and/or improve family communication,
functioning and relationships.
Multi-systemicTherapy
Intensive family- and community -based treatment program designed to make
positive changes in the various social systems (home, school, community, peer
relations} that contribute to the serious antisocial behaviors of children and
adolescents who are at risk for out -of -home placement.
RelinquishmentCounseling;
Relinquishment counseling for parents considering relinquishment of their
' children.
Substance Abuse Treatment
Services
Diagnostic and/or therapeutic services to assist in the development of the
Family Service Plan (FSP), to assess and/or improve family communication,
functioning and relationships, and to prevent further abuse of drugs or
alcohol.
Other
Creative and unique services designed to meet the needs of children,
youth antifamilies interacting with the Child Welfare system through a
prevention or traditional case.
B. Bids for the stated services will be received by the Weld County Department of Human Services, Resource
Unit, Attn: Tobi Vegter, through: MONDAY, APRIL 24, 2017, AT 5:00 P.M. (WELD COUNTY DEPARTMENT OF
HUMAN SERVICES, RESOURCE UNIT TIME CLOCK). Acceptable bid delivery methods are as follows:
Email. Emailed bids are preferred. Bids should be emailed to: vegterta@weldgov.com. Emailed bids must
include the following statement on the email: "I hereby waive my right to a sealed bid". An email
confirmation will be sent when we receive your bid/proposal.
Mail. Mailed bids should be sent in a sealed envelope with the bid title and bid number on it. Bids must include
the following statement on the email: "Thereby waive my right to a sealed bid". Mailed bids should be
addressed to: Weld County Department of Human Services, Attn: Tobi Vegter, Division of Child Welfare,
Financial Unit, P.O. Box A, Greeley, CO 80632. Please call or email Tobi Vegter at 970-400-6392 or
vegterta@weldgov.com if you have any questions.
Hand Delivery. Hand -delivered bids should be submitted in a sealed envelope with the bid title and bid number
on it. Bids must include the following statement on the email: "I hereby waive my right to a sealed bid". Hand -
delivered bids can be dropped off at: Weld County Department of Human Services, Attn: Tobi Vegter, Financial
Unit, 822 7th Street, Suite 150, Greeley, CO 80631. Please call or email Tobi Vegter at 970-400-6392 or
vegterta@weldgov.com if you have any questions.
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II. INVITATION TO BID
A. The Families, Youth and Children's Commission, on behalf of the Weld County Department of Human
Services, by and through the board of Weld County Commissioners requests bids for the purchase of Various
Services (as described above).
B. Bids shall include any and all charges for Service(s) applied for by the bidder, and shall, in every way, be the
total net price which the bidder will expect the Board of County Commissioners of Weld County to pay if
awarded the bid.
C. Emailed Bids Are Preferred. Emailed (fully typed) bids are preferred. However, if the bidder is unable to
submit an emailed bid, the bidder must comply with the requirements set forth in Paragraph I, B. An emailed
bid must contain the following statement: "I hereby waive my right to a sealed bid."
D. Unless the Bid is emailed, one original and one copy of the Bid must be submitted. One complete bid
document, which will be the only official copy of the bid, shall be filed at the Weld County Department of
Human Services, Resource Unit. After certification of the bid, the other copy will be routed for applicable
review. An e-mail confirmation will be sent when we receive your bid/proposal.
III.INSTRUCTIONS TO BIDDERS
A. Bids shall be typewritten. Each bid must give the full business address of the bidder and be signed by him
with his usual signature. Bids by partnerships must furnish the full names of all partners and must be signed
with the partnership name by one of the partners of the partnership or by an authorized representative,
followed by the signature and title of the person signing. Bids by corporations must be signed with the legal
name of the corporation, followed by the name of the state of the incorporation and by the signature and
title of the president, secretary, or other person authorized to bind it in this matter. Bids submitted by
limited liability companies must furnish the full names of all members and managers and must be signed by a
manager or by an authorized representative, followed by the signature and title of the person signing. The
name of each person signing shall also be typed or printed below the signature. A bid by a person who affixes
to his signature the word "president," "secretary," "agent," or other title without disclosing his principal, may
be held to be the bid of the individual signing. When requested, satisfactory evidence of the authority of
the officer signing in behalf of a corporation shall be furnished. All corrections or erasures shall be initialed by
the person signing the bid. All bidders shall agree to comply with all of the conditions, requirements,
specifications, and/or instructions of this bid as stated or implied herein. All designations and prices shall be
fully and clearly set forth.
B. Bids may be withdrawn upon written request to the Weld County Department of Human Services received
from bidders prior to the submission deadline. Negligence on the part of bidder in preparing the bid
confers no right for the withdrawal of the bid after it has been opened.
C. Bidders are expected to examine the conditions, specifications, and all instructions contained herein. Failure
to do so will be at the bidder's risk.
D. Bidders shall not stipulate in their proposals any conditions not contained in the instructions and
specifications herein unless specifically requested by the special instructions attached hereto. Any proposal
which fails to comply with the letter of the instructions and specifications herein may be rejected.
E. Late or unsigned bids shall not be accepted or considered. It is the responsibility of the bidder to ensure that
the bid arrives in the Weld County Department of Human Services, Service Utilization Unit, on or prior to the
time indicated in Section I., entitled "Notice to Bidders."
F. When approximate quantities are stated, Weld County reserves the right to increase or decrease quantity
as best fits its needs.
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G. Whenever requested, samples or descriptive matter shall be filed prior to the opening of bids.
H. In accordance with Section 14-9(3) of the Weld County Home Rule Charter, the Board of County
Commissioners of Weld County will give preference to resident Weld County bidders in all cases where
said bids are competitive in price and quality. It is also understood that the Board of County
Commissioners of Weld County will give preference to suppliers from the State of Colorado, in accordance
with Section 30-11-110, CRS, when it is accepting bids for the purchase of any books, stationery, records,
printing, lithographing or other supplies for any officer of Weld County.
I. All discounts shall be figured from the date of delivery and acceptance of the articles, or in the case of
an incorrect invoice, from the date of receipt of corrected invoice, if this be subsequent to delivery and
acceptance.
J. Substitutions or modifications to any of the terms, conditions, or specifications of this bid package which
are made by Weld County, Colorado, after the bids have been distributed to prospective bidders, and prior
to the date and time of bid opening, will be made in writing and signed by the Families, Youth and Children's
Commission. No employee of Weld County, Colorado, is authorized in any way to modify any of the terms,
conditions, or specifications of this bid without written approval of Families, Youth and Children's
Commission. This is not to imply that bids will not be accepted or considered with specifications which are
different from those herein. Any item which does not meet all the terms, conditions, or specifications of this
bid, must be clearly indicated on a separate sheet of paper, attached to the bid specification and proposal
sheets and returned with the bid.
K. The successful bidder shall indemnify and hold harmless Weld County, Colorado, against all claims for
royalties, for patents or suit for infringement thereon, which may be involved in the manufacture or use of the
material to be furnished.
L. Contractor certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-
101, et seq. Contractor shall not knowingly employ or contract with an illegal alien to perform work under
this Contract or enter into a contract with a subcontractor that fails to certify to Contractor that the
subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this
Contract. Contractor represents, warrants, and agrees that it (a) has verified that it does not employ any
illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the
Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the
requirements of C.R.S. 8-17.5-102(2)(b). Contractor shall comply with all reasonable requests made in the
course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If
Contractor fails to comply with any requirement of this provision or C.R.S. 8-17.5-101, et seq., Weld County may
terminate this Contract for breach and Contractor shall be liable for actual and consequential damages to Contractor.
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 this Contract, Contractor must confirm that any individual natural person
eighteen (18) years of age orolder 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 this 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 a Contract.
M.All goods shall remain the property of the seller until delivered to and accepted by Weld County, Colorado.
N. Bids received prior to the time of opening will be kept unopened in a secure place. No responsibility will
attach to the Families, Youth and Children Commission, the Weld County Department of Human Services, or
the Board of Weld County Commissioners, for the premature opening of a bid not properly addressed and
identified.
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0. In submitting the bid, the bidder agrees that the acceptance of any and all bids by the Board of County
Commissioners of Weld County within a reasonable time or period does not constitute a contract. The Board
of County Commissioners of Weld County, Colorado, reserves the right to reject any and 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.
P. These instructions, the proposal forms, and specifications have been developed with the hope of raising the
standard of purchasing negotiations to a level wherein all transactions will be mutually satisfactory. Your
cooperation is invited.
Q. Substitutions or modifications to any of the terms, conditions, or specifications of this which are made by
Weld County after the bids have been distributed to prospective bidders and prior to the date and time of bid
opening, will be made in writing. No employee of Weld County is authorized in any way to modify any of the
terms, conditions, or specifications of this bid without written approval of said Director of the Weld County
Department of Human Services. This is not to imply that bids will not be accepted or considered with
specifications which are different from those herein. Any item which does not meet all the terms, conditions,
or specifications of this bid, must be clearly indicated on a separate sheet of paper, attached to the bid
specification and proposal sheets and returned with the bid.
IV.GENERAL SPECIFICATIONS
A. Fund Availability: Financial obligations of the Weld County payable after the current fiscal year are
contingent upon funds for that purpose being appropriated, budgeted and otherwise made available. By
acceptance of the bid, Weld County does not warrant that funds will be available to fund the contract beyond the
current fiscal year.
B. Governmental Immunity: No term or condition of the 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 §§24- 10-101 et seq., as applicable now or hereafter amended.
C. Independent Contractor: The successful bidder shall perform its duties hereunder as an independent
contractor and not as an employee. He or she shall be solely responsible for its acts and those of its agents and
employees for all acts performed pursuant to the contract. Neither the successful bidder nor any agent or
employee thereof shall be deemed to be an agent or employee of Weld County. The successful bidder and its
employees and agents are not entitled to unemployment insurance or workers' compensation benefits
through Weld County and Weld County shall not pay for or otherwise provide such coverage for the
successful bidder or any of its agents or employees. Unemployment insurance benefits will be available to the
successful bidder and its employees and agents only if such coverage is made available by the successful bidder
or a third party. The successful bidder shall pay when due all applicable employment taxes and income taxes
and local head taxes (if applicable) incurred pursuant to the contract. The successful bidder shall not have
authorization, express or implied, to bind Weld County to any agreement, liability or understanding, except as
expressly set forth in the contract. The successful bidder 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 (b)
provide proof thereof when requested to do so by Weld County.
D. Compliance with Law: The successful bidder shall strictly comply with all applicable federal and State laws,
rules and regulations in effect or hereafter established, including without limitation, laws applicable to
discrimination and unfair employment practices.
E. Choice of Law: Colorado law, and rules and regulations established pursuant thereto, shall be applied in the
interpretation, execution, and enforcement of the contract. Any provision included or incorporated herein by
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reference which conflicts with said laws, rules and/or regulations shall be null and void.
F. Binding Arbitration Prohibited: Weld County does not agree to binding arbitration by any extra -judicial body
or person. Any provision to the contrary in the contract or incorporated herein by reference shall be null and
void.
G. No Third Party Beneficiary Enforcement: It is expressly understood and agreed that the enforcement of the
terms and conditions of the contract, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties and nothing in the contract shall give or allow any claim or right of action
whatsoever by any other person not included in the contract. It is the express intention of the undersigned
parties that any entity other than the undersigned parties receiving services or benefits under the contract
shall be an incidental beneficiary only.
H. Attorney Fees/Legal Costs: In the event of a dispute between Weld County and the successful bidder,
concerning the contract, the parties agree that Weld County shall not be liable to or responsible for the
payment of attorney fees and/or legal costs incurred by or on behalf of the successful bidder.
V. Insurance Requirements
i. General Requirements: Contractors/Contract Professionals 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/Contract Professionals shall keep the required
insurance coverage in force at all times during the term of the Agreement, or any extension thereof, during any
warranty period, and for three (3) years after termination of the Agreement. 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, County must be notified by the
Contractor/Contract Professional. Contractor/Contract Professional shall be responsible for the payment of any
deductible or self -insured retention. County reserves the right to require Contractor/Contract Professional to
provide a bond, at no cost to County, 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/Contract Professional.
Contractor/Contract Professional 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.
ii. Types of Insurance: Contractor/Contract Professional shall obtain, and maintain at all times during the
term of any Agreement, insurance in the following kinds and amounts:
(a). Workers' Compensation Insurance as required by state statute, and Employer's Liability Insurance
covering all of Contractor's Contract Professional'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.
(b). Commercial General Liability Insurance written on ISO occurrence form CG 00 01 10/93 or equivalent,
covering premises operations, fire damage, independent Contractors, products and completed operations,
blanket contractual liability, personal injury, and advertising liability with minimum limits as follows:
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• $1,000,000 each occurrence;
• $2,000,000 general aggregate;
• $50,000 any one fire; and
• $500,000 errors and omissions.
(c). Automobile Liability: Contractor/Contract Professional 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.
(d). Additional Provisions:
• Policies for all general liability, excess/umbrella liability, liquor liability and pollution liability must
provide the following:
• If any aggregate limit is reduce by twenty-five percent (25%) or more by paid or reserved claims,
Contractor shall notify County 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
County.
(e). 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 County, whichever is earlier.
iii. Contractors/Contract Professionals 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 Bid.
iv. Proof of Insurance: Contractor/Contract Professional shall provide a copy of this information to its
insurance agent or broker, and shall have its agent or broker provide proof of Contractor/Contract
Professional's required insurance to the County. County reserves the right to require Contractor/Contract
Professional 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.
v. Additional Insureds: For general liability, excess/umbrella liability, pollution legal liability, liquor liability,
and inland marine, Contractor/Contract Professional's insurer shall name County as an additional insured.
vi. Waiver of Subrogation: For all coverages, Contractor/Contract Professional's insurer shall waive subrogation
rights against County.
vii. Subcontractors: All subcontractors, 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/Contract
Professional. Contractor/Contract Professional 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.
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Contractor/Contract Professional agrees to provide proof of insurance for all such subcontractors,
independent contractors, sub -vendors suppliers or other entities upon request by the County.
A provider of Professional Services (as defined in the Bid or RFP) shall provide the following coverage:
Professional Liability: Contract Professional shall maintain limits of $1,000,000 for each claim, and $2,000,000
aggregate limit for all claims.
VI.Warranty. The successful bidder shall warrant that:
A. The services to be supplied pursuant to this bid are fit and sufficient for the purpose intended;
B. The services sold to Weld County, Colorado pursuant to this bid conform to the minimum Weld County
specifications as established herein.
VI. CONFIDENTIAL INFORMATION
Confidential financial information of the bidder should be transmitted separately from the main bid submittal,
clearly denoting in red on the financial information at the top the word, "CONFIDENTIAL." However, the
successful bidder is advised that as a public entity, Weld County must comply with the provisions of
C.R.S. 24-72-201, et seq., the Colorado Open Records Act (CORA), with regard to public records, and cannot
guarantee the confidentiality of all documents. If Weld County receives a CORA request for bid information
marked "CONFIDENTIAL", staff will attempt to contact the bidder in order to allow the bidder to seek an
appropriate court order preventing disclosure. Without such an order, Weld County will release the requested
information in accordance with CORA.
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SCOPE OF SERVICES
PURPOSE: The Weld County Department of Human Services (WCDHS) is seeking qualified English-
speaking and bilingual (English/Spanish) providers in various service areas under various funding sources.
Service areas include, but are not limited to, Anger Management/Domestic Violence, Day Treatment,
Foster Parent Consultation, Foster Parent Training, Functional Family Therapy, Kinship Services
(Therapeutic), Home Studies/Relinquishment Counseling, Life Skills, Mediation, Mental Health,
Monitored Sobriety, Multi -Systemic Therapy, Home Based Intervention including 24/7 Crisis Intervention,
Sexual Abuse Treatment, and Substance Abuse Treatment Services and Aftercare Services.
SERVICE AREAS ARE NOTED BEGINNING ON PAGE 1 OFTHIS REQUEST FOR BID, BUT ARE NOT LIMITED
TO THOSE LISTED. OTHER SERVICES WILL BE CONSIDERED AND BIDDERS ARE ENCOURAGED TO SUBMIT
FOR UNIQUE AND CREATIVESERVICES.
Qualifications:
To be considered, a bidder must meet the following minimum qualifications:
1) Complete a Provider Information Form (PIF).
2) If submitting to provide bilingual services, a bidder must demonstrate language proficiency at Full
Professional Proficiency or higher, as defined by the U.S. Department of State, and as noted below.
• Full Professional Proficiency: Able to use and read the language fluently and accurately on all
levels pertinent to professional needs
• Native or Bilingual Proficiency: Equivalent to that of an educated native speaker (both speaking
and reading).
3) A bidder must agree to language proficiency testing that may include assessment of reading, writing
and comprehension of Spanish, as well as a face-to-face conversation with a known native or proficient
Spanish speaker selected by Weld County.
4) A bidder must submit a one page or less cover letter that introduces the bidder, the bidder's
location(s) of practice and target area, his or her experience and qualifications, and staff, if applicable. A
bidder must include current contact information including physical address, mailing address, phone
number, email address and website, if applicable.
5) A bidder must submit sufficient information concerning each proposed service for Weld County to
i
evaluate whether or not the bidder meets "minimum qualifications" for all bidders. Each service must be
submitted as its own proposal, inclusive of scope of services and rate information. The scope of service
should include at a minimum the following information for each service proposed:
• Detailed description of service components, modalities used, appropriate use of service, etc.
• Target population including age range, specific population characteristics, area of service, etc.
• Whether or not the service is billable to Medicaid and if bidder is currently able to bill Medicaid.
Bidders are strongly encouraged to become Medicaid certified. Medicaid -billable services are
preferred.
• Clear rate schedule inclusive of all costs bidder wishes to charge for the provision of the service.
6) A bidder should avoid elaborate artwork, graphics, binding, presentation or other artifice that does
not directly address the requirements set forth in this Request for Bid.
7) A bidder must demonstrate the knowledge, training and expertise to conduct the proposed service(s).
8) A bidder must provide a current resume, as well as proof of licensure, for self, staff members and
contractors of the bidder. Additionally, a bidder must include proof of inclusion on State vendor lists if
applicable to the proposed service (ex. Home Study Providers, Sex Offender Management Board
Providers).
9) A bidder should clearly outline the supervisory structure of staff members and/or contractors of the
bidder. This should include the ratio of supervisor to staffand/or contractors, frequency and duration of
supervision, credentials of supervisor and length of time as a supervisor.
10) A bidder should clearly outline the bidder's internal referral acceptance and assignment protocol,
including communication to the referring agency.
11) A bidder must demonstrate familiarity with Trauma Informed Care. Bidder must provide copies of
applicable training certificates, or proof of registration for training, for all staff members who manage
and/or administer services under this proposal.
12) A bidder must demonstrate prior and current capacity to be organized, responsive and to quickly
and successfully schedule services as requested.
13) A bidder must agree to track outcome data related to services proposed if awarded a contract and
report outcomes upon request.
14) A bidder must agree to enter into an agreement, attached as Exhibit A, with the Weld County
Department of Human Services and comply with all requirements of the agreement.
Contract Period and Pricing:
1) The initial contract period is to be determined and shall continue as allowable by the funding source,
so long as both parties are satisfied. The selected vendor(s) will have the opportunity to resubmit
annually.
2) The initial contract will be funded through Core Services Program or other funding, so long as funding
is made available.
3) The selected vendor will bill the Weld County Department of Human Services monthly according to
billing requirements set forth by the Weld County Department of Human Services.
Submittal Requirements for All Proposals:
A bidder must submit according to requirements set forth in this Request for Bid - Qualifications. All
proposals must contain the following specific information:
1) Provider Information Form (PIF).
2) Identification of language(s) and proficiency level, if applying to provide bilingual (English/Spanish)
services.
3) One page or less cover letter that introduces the bidder, the bidder's location(s) of practice, his or her
experience and qualifications, and staff, if applicable.
4) A bidder must submit sufficient information concerning each proposed service for Weld County to
evaluate whether or not the bidder meets"minimum qualifications" for all bidders. Each service must
be submitted as its own proposal, inclusive of scope of services and rate information. The scope of
service should include at a minimum the following information for each service proposed:
• Detailed description of service components, modalities used, appropriate use of service, etc.
• Target population including age range, specific population characteristics, area of service, etc.
• Whether or not the service is billable to Medicaid and if bidder is currently able to bill Medicaid.
Bidders are strongly encouraged to become Medicaid certified. Medicaid -billable services are
preferred.
• Clear rate schedule inclusive of all costs bidder wishes to charge for the provision of the service.
5) Bidders should avoid elaborate artwork, graphics, binding, presentation or other artifice that does not
directly address the requirements set forth in this Request for Bid.
6) Current resume, proof of licensure and copies of applicable training certificates for all staff members
who will manage and/or administer services under this proposal.
7) Supervisory structure of staff members and/or contractors of the bidder. This should include the ratio
of supervisor to staff and/or contractors, frequency and duration of supervision, credentials of supervisor
and length of time as a supervisor.
8) Internal referral acceptance and assignment protocol, including communication to the referring
agency.
9) All proposals must demonstrate the bidder has the ability to deliver the services as proposed, and
comply with the specific requirements set forth by the Weld County Department of Human Services.
10) All proposals must include a clear and concise rate schedule that accurately correlates to the
proposed services and is inclusive of all possible charges related to the proposed service(s). The rate
schedule must demonstrate an exact fee for the described service (s). Approximate rates or a range of
rates for a service will not be accepted.
11) Each bidder must submit a Standard Certificate of Insurance, or letter of intent from an insurance
company authorized to do business in the State of Colorado stating its willingness to insure the bidder
pursuant to the terms of this Request for Bid.
Evaluation of Proposals:
All proposals that meet the basic proposal, service and qualification requirements will be reviewed by the
Families, Youth and Children (FYC) Commission. Criteria for review, include but are not limited to the
following:
• Qualifications, appropriate licensure, and experience.
• Cost structure.
• Relationships and collaboration.
• Organizational experience and past performance.
The FYC Commission will make recommendations to the Board of Weld County Commissioners by and
through the Weld County Department of Human Services. The Weld County Department of Human
Services will make its award of contract to the successful bidders upon final approval of the Board of
Weld County Commissioners.
EXHIBIT A
SAMPLE AGREEMENT
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND
This Agreement, made and entered into the _ day of , 2015, 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 «Contractor», 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 Reuquest for Proposal, Exhibit B, Contractor's Proposal,
Exhibit C, Scope of Services, and Exhibit D, Payment Schedule. Each of these documents is attached hereto and
incorporated herein by this reference.
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 funding to the Department
for
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows:
1. Term
This agreement shall become effective on , upon proper execution of this Agreement and shall
expire , 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 Department's Resource Manager, Child Welfare Contract and Services Coordinator, or
through a Team Decision Making (TDM) meeting or Family Team Meeting (FTM). No other
Department staff or other party to the case may authorize services or modifications to services.
c. Contractor agrees to submit an itemized complete billing statement by the 7th of the month,
following the month of service, utilizing billing forms required by the Department.
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d. Contractor agrees to submit a monthly report with the billing statement by the 7"' of the month
following the month of service for each client receiving ongoing services. One-time services will be
verified through receipt of the completed product (ex. psychological evaluation, substance abuse
evaluation). Verification of Monitored Sobriety Services will be the test result.
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.
Monthly reports will be submitted through the Department's online reporting system, unless
otherwise directed or agreed to by the Department.
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.
b. Payment shall be made in accordance with Exhibit A, Weld County's Request for Proposal, Exhibit
B, Contractor's Proposal, Exhibit C, Scope of Services, and Exhibit D, Payment Schedule, attached
hereto and incorporated herein by reference, so long as services are rendered satisfactorily and in
accordance with the Agreement.
c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent
upon, the continuing availability of said funds for the purposes hereof.
d. The Department may withhold reimbursement if Contractor has failed to comply with any part of
the Agreement, including the Financial Management requirements, program objectives, contractual
terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may
appeal such circumstance in writing to the Director of Human Services. The decision of the Director
of Human Services shall be final.
5. Financial Management
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,
Payment 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 ACH Form for Colorado Providers, which will be
provided by the Department. Contractor is solely responsible to submit the ACH Form to the State of
2
Colorado per the directions on the form. Failure to complete and submit this form in a timely and
accurate manner may result in a delay of payment.
c. Contractor agrees to accept payment through county warrant when funding source does not
allow for direct deposit.
7. Compliance with Applicable Laws
a. At all times during the performance of this Agreement, Contractor will strictly adhere to all
applicable Federal and State laws, order, and applicable standards, regulations, interpretations
and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all
applicant/recipient records, papers, documents, tapes and any other materials that have been or may
hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws
and regulations, including, but not limited to the following:
- Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil
Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45
C.F.R. Part 80 et. seq.; and
- all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of
race, creed, color, sex, or national origin, be excluded from participation in, be denied the
benefits of, or be otherwise subjected to discrimination under the approved Agreement.
- Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its
implementing regulations, 45 C.F.R. Part 84; and
- the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its
implementation regulations, 45 C.F.R. Part 91; and
- Title VII of the Civil Rights Act of 1964; and
- the Age Discrimination in Employment Act of 1967; and
- the Equal Pay Act of 1963; and
- the Education Amendments of 1972; and
- Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and
- all regulations applicable to these laws prohibiting discrimination because of race, color,
national origin, sex, religion, and handicap, including Acquired Immune Deficiency Syndrome
(AIDS) or AIDS related conditions covered under Section 504 of the 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.
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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 Core Services.
d. Contractor assures and certifies that it and its principals:
- Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from covered transaction by a Federal or State department or agency;
and
- have not, within a three-year period preceding this Agreement, been convicted of or
had a civil judgment rendered against them for commission of fraud or criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State or
Local) transaction or contract under public transaction; violation of federal or state antitrust
statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction
of records, making false statements, or receiving stolen property; and
- are not presently indicted for or otherwise criminally or civilly charged by a government
entity (federal, state or local) with commission of any of the offenses enumerated in this
certification; and
- have not, within a three-year period preceding this Agreement, had one or more public
transactions (federal, state, or local) terminated for cause or default.
e. Public Contracts for Services C.R.S. §8-17.5-101. Contract Professional certifies, warrants, and
agrees that it does not knowingly employ or contract with an illegal alien who will perform work under
this contract. Contract Professional 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). Contract Professional 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 Contract Professional that the subcontractor shall not knowingly employ or contract with an illegal
alien to perform work under this Agreement. Contract Professional 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 Contract Professional obtains actual knowledge that a
subcontractor performing work under the public contract for services knowingly employs or contracts
with an illegal alien Contract Professional shall notify the subcontractor and County within three (3)
days that Contract Professional 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. Contract Professional 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. Contract
Professional 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 Contract
Professional participates in the State of Colorado program, Contract Professional shall, within twenty
days after hiring a new employee to perform work under the contract, affirm that Contract Professional
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. Contract Professional shall deliver
to County, a written notarized affirmation that it has examined the legal work status of such employee,
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and shall comply with all of the other requirements of the State of Colorado program. If Contract
Professional fails to comply with any requirement of this provision or of C.R.S. §8-17.5-101 et seq.,
County, may terminate this Agreement for breach, and if so terminated, Contract Professional 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
Contract Professional receives federal or state funds under the contract, Contract Professional 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 Contract Professional operates as a sole proprietor, it hereby swears
or affirms under penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully
present in the United States pursuant to federal law, (b) shall produce one of the forms of
identification required by C.R.S. § 24-76.5-101, et seq., and (c) shall produce one of the forms of
identification required by C.R.S. § 24-76.5-103 prior to the effective date of the contract.
8. Compliance with Child and Family Services Review
The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas;
Safety, Permanency and Well Being of families. For each outcome, data and performance indicators
measure each state's performance according to national standards and monitor progress over time.
Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance
services to families.
Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well
Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under
this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under
the Child and Family Services Review (CFSR), and will address the aforementioned three areas when
completing monthly reports as required by Paragraph 3(d) of this Agreement.
9. Insurance Requirements
Contractor and 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/Contract Professionals 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/Contract
Professionals shall keep the required insurance coverage in force at all times during the term of
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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, County must be notified by the Contractor/Contract
Professional. Contractor/Contract Professional shall be responsible for the payment of any
deductible or self -insured retention. County reserves the right to require Contractor/Contract
Professional to provide a bond, at no cost to County, 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/Contract Professional. Contractor/Contract Professional 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/Contract Professional shall obtain, and maintain at all
times during the term of any Agreement, insurance in the following kinds and amounts:
Workers' Compensation Insurance as required by state statute, and Employer's
Liability Insurance covering all of Contractor's Contract Professional's employees acting
within the course and scope of their employment. If Contractor is an Independent
Contractor, as defined by the Colorado Worker's Compensation Act, this requirement
shall not apply. Contractor must submit to the Department a Declaration of Independent
Contractor Status Form prior to the start of this agreement.
ii. Commercial General Liability Insurance written on ISO occurrence form CG 00
01 10/93 or equivalent, covering premises operations, fire damage, independent
Contractors, products and completed operations, blanket contractual liability, personal
injury, and advertising liability with minimum limits as follows:
$1,000,000 each occurrence;
- $2,000,000 general aggregate;
- $50,000 any one fire; and
- $500,000 errors and omissions.
iii. Automobile Liability: Contractor/Contract Professional 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 reduce by twenty-five percent (25%) or more
by paid or reserved claims, Contractor shall notify County 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 County.
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 County, whichever is earlier.
c. Contractors/Contract Professionals 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/Contract Professional shall provide a copy of this
information to its insurance agent or broker, and shall have its agent or broker provide proof of
Contractor/Contract Professional's required insurance. County reserves the right to require
Contractor/Contract Professional 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/Contract Professional's insurer shall name County as
an additional insured as follows
f. Waiver of Subrogation: For all coverages, Contractor/Contract Professional's insurer
shall waive subrogation rights against County.
B. Subcontractors: All subcontractors, 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/Contract Professional. Contractor/Contract Professional 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/Contract Professional agrees to provide proof of insurance for all such subcontractors,
independent contractors, sub -vendors suppliers or other entities upon request by the County.
A provider of Professional Services (as defined in the Bid or RFP) shall provide the following
coverage:
Professional Liability: Contract Professional 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
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Contractor may be required to attend training that 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 970-352-1551, x6503, 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 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. As the
monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special
analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such
monitoring shall be performed in a manner that will not unduly interfere with 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.
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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, Administrator CONTRACTOR, TITLE
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) 352-1551
18. Litigation
For Contractor:
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 18. 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
9
any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental
Immunity Act of §§24-10-101 et. seq., as applicable now or hereafter amended.
22. Partial Invalidity of Agreement
If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held
or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions.
The parties hereto declare that they would have entered into this Agreement and each and every section,
subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more
sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional
or invalid.
23. Improprieties/Conflict of Interest
No officer, member or employee of Weld County and no member of their governing bodies shall have any
pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof.
The Appearance of Conflict of Interest applies to the relationship of a Contractor with the Department
when the Contractor also maintains a relationship with a third party and the two relationships are in
opposition. In order to create the appearance of a conflict of interest, it is not necessary for the
Contractor to gain from knowledge of these opposing interests. It is only necessary that the Contractor
know that the two relationships are in opposition. During the term of the Agreement, Contractor shall
not enter into any third party relationship that gives the appearance of creating a conflict of interest.
Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the
Department, a full disclosure statement setting forth the details that create the appearance of a conflict
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.
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.
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25. Confidentiality of Records
Contractor shall protect the confidentiality of all applicant records and other materials that are
maintained in accordance with this Agreement except for purposes directly connected with the
administration of Child Protection. No information about or obtained from any applicant/recipient in
possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minor's
parent or guardian unless in accordance with the Contractor's written policy governing access to,
duplication and dissemination of, all such information, in any form, including social networks. Contractor
shall advise its employees, agents, and subcontractor, if any, that they are subject to these confidentiality
requirements.
Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written
explanation of these confidentiality requirements before access to confidential data is permitted.
Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality
agreement and shall provide a copy of such agreement to the Department, if requested.
26. 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
Contract Professional agrees that it is an independent Contract Professional and that Contract
Professional'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. Contract Professional shall
perform its duties hereunder as an independent Contract Professional. Contract Professional shall be
solely responsible for its acts and those of its agents and employees for all acts performed pursuant to
this Agreement. Contract Professional, 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 Contract Professional or any of its agents or employees. Unemployment
insurance benefits will be available to Contract Professional and its employees and agents only if such
coverage is made available by Contract Professional or a third party. Contract Professional shall pay when
due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred
pursuant to this Agreement. Contract Professional shall not have authorization, express or implied, to
bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement.
Contract Professional 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
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
11
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.
31. Acceptance of Services Not a Waiver
Upon completion of the work, the Contractor shall submit to Department originals of all tests and results,
reports, etc., generated during completion of this work. Acceptance by 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 conflict 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
Contract Professional'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.
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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, Contract Professional agrees that the Weld County District Court shall have exclusive
jurisdiction to resolve said dispute.
35. Subcontractors
Contract Professional acknowledges that County has entered into this Agreement in reliance upon the
particular reputation and expertise of Contract Professional. Contract Professional shall not enter into any
subcontractor agreements for the completion of this project without County's prior written consent, which
may be withheld in County's sole discretion.
36. Attorneys Fees/Legal Costs
In the event of a dispute between County and Contract Professional, 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 Contract Professional under this Agreement or individual work order
shall become or remain (as applicable), the property of County. In addition, all reports, documents, data,
plans, drawings, records and computer files generated by Contract Professional 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 County. Contract Professional shall not make use of such
material for purposes other than in connection with this Agreement without prior written approval of
County.
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.
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IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first
above written.
ATTEST: BOARD OF COUNTY COMMISSIONERS
Weld County Clerk to the Board WELD COUNTY, COLORADO
BY:
Deputy Clerk to the Board , Chair
APPROVED AS TO FUNDING: APPROVED AS TO SUBSTANCE:
Controller Elected Official or Department Head
APPROVED AS TO FORM:
Director of General Services
County Attorney
CONTRACTOR
Contractor, Title
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Provider Contract Request 2017-2018
Submitted for Review by Weld County Department of Human Services
Contractor
Milestones Counseling Services, LLC
832 W. Eisenhower Blvd. Suite C
Loveland, CO 80537
addie.campbell@milestonescounseling.com
Addie Campbell, MA, LPC, RPT-S
(970) 403-7656
Milestones Counseling Services, LLC 2
2017-2018 Contract Proposal
Milestones Counseling Services (MCS) is located in Loveland, Colorado with office and in -home services
available for foster parent consultation throughout Weld County and surrounding areas. MCS provides
mental health and consultation services for adults, families and children. MCS is experienced in
providing family therapy and consultation services that are strength -based and focused on fostering safe
and stable child -family relationships. Because of the dependence of children on their home
environment, MCS emphasizes the stability and involvement of the caregivers throughout the treatment
process.
Staff members for MCS include:
Addie Campbell —Addie is a Licensed Professional Counselor and Registered Play Therapist -Supervisor.
She has worked in the Mental Health Field for 20 years and has experience in child and family therapy,
trauma counseling, home study evaluations, parenting consultation, and relinquishment counseling. She
is fluent in Spanish and English and has experience utilizing Spanish to provide professional services to
clients in either English or Spanish language. Addie is registered with the Colorado Department of
Regulatory Agencies (License #3262).
Milestones Counseling Services, LLC 3
2017-2018 Contract Proposal
FOSTER PARENT CONSULTATION
SCOPE OF SERVICE:
As in any family system (whether it be biological or foster), the dynamics of the family change when a
child(ren) enter the home or have personal problems. Many times, foster parents require additional
support in dealing with special needs or circumstances that accompany a child when entering the foster
home.
Common issues that put placement at risk include: 1) foster parents perceiving a lack of support from
providers to effectively deal with the escalating behaviors of a child; 2) foster parents feeling poorly
equipped to appropriately deal with specific behaviors of the child such as aggression, inappropriate
behavior, or attachment problems; and 3) foster parents interpreting acting out behaviors as rejection
by the child, and misidentifying the child's underlying issues; e.g., termination of parental rights,
visitations with parents, past trauma reactions, etc. This information becomes significant when
implementing services for foster parents in efforts of safeguarding placement.
The target population for this service is for foster parents caring for children placed out of their home
due to abuse, neglect, and trauma. Children in foster parents' care range in age from infant through
adolescence and services/interventions will include parenting approaches that are appropriate for each
age of the child.
MCS will emphasize a collaborative approach in working with foster parents to maximize the benefit of
therapeutic strategies Being implemented in the home. It is the goal of MCS to support the foster family
in providing the most appropriate and safest care possible for the foster child and thereby preserving
the foster placement a long as deemed necessary by the Department of Human Services.
This service is not billable to Medicaid and MCS is not considered Medicaid certified.
MODE OF SERVICE:
1. MCS will respond to a WDHS referral within one business day of receiving the referral to
include: responding to the referring party via e-mail or phone call that the referral has been
received as well as making contact with the foster parent identified in the referral.
2. MCS will obtain necessary case information from foster care coordinator or case worker that
is relevant and helpful in preparation of meeting with the foster parents.
Milestones Counseling Services, LLC 4
2017-2018 Contract Proposal
3. Although MCS will use telephonic calls to schedule consultations with foster parents, Foster
parent consultation services are only provided directly and in person. Location of services
will be primarily at the foster parents' home. Services can be provided at MCS office, if
requested by the foster parent.
4. MCS will meet with foster parents to gather information on their concerns and prior
attempts at meeting the child's needs. Gather information on parenting style, barriers to
relationship formation between child and parent, if any, and plan for intervention.
5. Provide feedback and intervention strategies to improve foster parent -foster child
interaction and decrease behavior problem areas.
6. Interventions are based on parenting approaches that take into consideration trauma,
neglect, and abuse histories. These approaches draw on skills utilizing the Beyond
Consequences (Heather Forbes) parenting interventions. Interventions will include helping
foster families increase their knowledge on issues related to: emotion regulation, stress
tolerance, hoarding, aggression, and defiance.
7. Throughout foster parent consultation, ongoing evaluation of interventions and progress in
foster parent -foster child interaction.
8. Pre and post assessment: MCS will provide foster parents with the Parenting Relationship
Questionnaire (PRQ) for objective measure of progress. The PRQ is used to assess different
parenting relationships, beliefs, and practices among parents or other caregivers. This
instrument also provides information that can be used during the intervention stage. Areas
measured include: Relational frustration (caregivers' level of stress or distress in parenting);
Parenting Confidence; Involvement; Discipline Practices; Communication.
9. MCS will complete online reporting to DHS about interview, observation of foster family -
child interactions, interventions recommended, feedback on the implementation of
intervention and response between child -foster family in relation to intervention, and any
concerns and further recommendations.
COST OF SERVICE:
Foster Parent Consultation $100/hour
Approved attendance (by Contract and Service Coordinator) at TDM or FTM $80/hour
Court Testimony (per hour/minimum 1 hour) $200/hour
Mileage rate reimbursement in excess of 30 miles from Greeley $0.54/mile
EXHIBIT C
SCOPE OF SERVICES
1. Contractor will provide Foster Parent Consultation services to children, youth and families, as referred by the
Department.
2. Foster Parent Consultation:
a. Contractor will work collaboratively with children, foster parents, caseworkers, foster care
coordinators and other service providers to identify and address issues, in a solution -focused manner
that could potentially disrupt placements.
b. Contractor will assess foster families abilities and capacity on an ongoing basis to appropriately care
for the foster children in their home and report this information on a monthly basis to the
Department.
c. Contractor will conduct services in the following manner:
i. Contractor will meet with the foster home parent(s) to gather information regarding their
specific concerns and prior attempts to meet the child's specific needs.
ii. Contractor will provide parents with the Parenting Relationship Questionnaire (PRQ). The
PRQ takes 10-15 minutes to complete and is used to assess different parenting
relationships, beliefs, and practices among parents and/or caregivers. It is appropriate for
the assessment of parents or caregivers of children aged two (2) to 18. The PRQ measures
caregivers' level of stress or distress in parenting, parenting confidence, involvement,
discipline practices and communication.
iii. Contractor will meet with the foster child, if age appropriate, to gather information about
any concerns or barriers to maintaining the placement.
iv. Contractor will observe foster child and parents to gather additional information on
parenting style, barriers to the formation of the parent/child relationship, possible "hot
spots", and to develop an intervention plan.
v. Contractor will meet with foster child and parents to provide feedback following
implementation of the intervention plan to assess progress.
vi. Contractor will administer the PRQ again at the conclusion of services to measure the level
of change.
vii. Contractor can conduct additional sessions/follow-up if approved by the Department.
d. Contractor will conduct services in the following manner:
i. Contractor will obtain pertinent information from the caseworker.
ii. Contractor will meet with the family and conduct a life skills assessment to identify
deficiencies and set goals.
iii. Contractor will provide education, concrete lessons and will model concepts as a means of
teaching skills and working towards goals.
3. Contractor can provide bilingual services (Spanish).
4. 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.
5. 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.
1
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
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.
9. Contractor understands that the Department will not reimburse Contractor for "no shows" or cancelled
appointments, either on the part of the client or the Contractor.
10. 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.
Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise
approved by the Child Welfare Contract and Services Coordinator.
2
EXHIBIT D
PAYMENT 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 specified 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 in Trails after May 31,
2018.
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
Foster Parent Consultation:
$100.00/Hour (Foster Parent Consultation)
$80.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting)
Mileage shall be reimbursed after the first 30 miles at two cents below the most current IRS rate/mile.
Contractor may not attempt to collect co -pays and/or fees for services for which a Department client is
responsible, but which a particular client refuses or fails to pay.
Contractor will collect any applicable sliding scale co -pays and credit the Department for any payment
received on the monthly billing.
3. Submittal of Vouchers
Contractor shall prepare and submit monthly an itemized voucher, and signed monthly report if
applicable, certifying that services authorized were provided on the date(s) indicated and the charges
made were pursuant to the terms and conditions of Paragraph 3 and Exhibit A.
Contractor shall submit all monthly billings and applicable reports to the Department by the 7th day of the
month following the month the cost was incurred. Failure to submit by the aforementioned deadline may
result in forfeiture of payment.
a. 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.
1
b. For one-time services, proof of services rendered shall be receipt of the completed product.
c. For Monitored Sobriety services, proof of services rendered shall be the test result.
HEALTHCARE PROVIDERS SERVICE 1111-1PSO
CNA ORGANIZATION PURCHASING GROUP
Producer Branch Prefix
018098 970 HPG
Named Insured and Address:
Adelaide Campbell
904 49th Avenue Ct
Greeley, CO 80634-1912
Medical Specialty:
Licensed Professional Counselor
Excludes Cosmetic Procedures
Certificate of J nourante
OCCURRENCE POLICY FORM
Policy Number
0299197210
Healthcare Pnntidcrs Scnice Orpnizntion-
Print Date: 9/23/2016
Policy Period
from 09/14/16 to 09/14/17 at 12:01 AM Standard Time
Program Administered by:
Healthcare Providers Service Organization
159 E. County Line Road
Hatboro, PA 19040-1218
1-800-982-9491
www.hpso.com
Code: Insurance is provided by:
80723
American Casualty Company of Reading, Pennsylvania
333 S. Wabash Avenue, Chicago, IL 60604
Professional Liability $1,000,000 each claim
Your professional liability limits shown above include the following:
* Good Samaritan Liability * Malplacement Liability * Personal Injury Liability
* Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit
Coverage Extensions
License Protection $ 25,000 per proceeding $ 25,000
Defendant Expense Benefit $ 1,000 per day limit $ 25,000
Deposition Representation $ 10,000 per deposition $ 10,000
Assault $ 25,000 per incident $ 25,000
Includes Workplace Violence Counseling
Medical Payments $ 25,000 per person $ 100,000
First Aid $ 10,000 per incident $ 10,000
Damage to Property of Others $ 10,000 per incident $ 10,000
Information Privacy (HIPAA) Fines and Penalties $ 25,000 per incident $ 25,000
General Liability
General Liability
Fire & Water Legal Liability
Personal Liability
Total: $ 317.00
$ 5,000,000 aggregate
aggregate
aggregate
aggregate
aggregate
aggregate
aggregate
aggregate
aggregate
$1,000,000 each claim / $1,000,000 aggregate
Included in the GL limit shown above subject to $250,000 aggregate sublimit
$1,000,000 aggregate
Base Premium $317.00
Premium reflects Self Employed , Part Time
Policy Forms & Endorsements(Please see attached list for a general description of many common policy forms and
endorsements.)
G -121500-D
GSL15565
CNA81753
G -121501-C
GSL17101
CNA81758
Chairman of the Board
Secretary
G -141241-B (03/2010)
G -145184-A
GSL13424
CNA82011
G -147292-A
CNA80051
CNA79575
Coverage Change Date:
GSL15563
CNA80052
G -121487-B
GSL15564
G -123846-005
G -121504-C
Keep this document in a safe place.lt
and proof of payment are your proof of
coverage. There is no coverage in force
unless the premium is paid in full. in order
to activate your coverage, please remit
premium in full by the effective date of
this Certificate of Insurance.
Master Policy # 188711433
Endorsement Change Date:
POLICY FORMS & ENDORSEMENTS
The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your
professional liability insurance policy. Please refer to your Certificate of Insurance for the policy forms &
endorsements specific to your state and your policy period. Coverages, rates and limits may differ or may not be
available in all states. All products and services are subject to change without notice.
Think Green —expanded definitions and copies of these policy forms and endorsements are available online at
www.hpso.com/policyforms
COMMON POLICY FORMS & ENDORSEMENTS
FORM # DESCRIPTION
G -121500-D
G -121501-C
G -145184-A
G -147292-A
GSL15563
GSL15564
GSL15565
GSL17101
GSL13424
CNA80051
CNA80052
G -123846-005
CNA81753
CNA81758
CNA82011
CNA79575
Common Policy Conditions
Occurrence Policy Form
Policyholder Notice - OFAC Compliance Notice
Policyholder Notice - Silica, Mold & Asbestos Disclosure
Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs
Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion
Healthcare Providers Professional Liability Assault Coverage
Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies
Services to Animals
Amended Definition of Personal Injury Endorsement
Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement
Colorado Cancellation and Non -Renewal
Coverage & Cap on Losses from Certified Acts Terrorism
Notice - Offer of Terrorism Coverage & Disclosure of Premium
Related Claims Endorsement
Exclusion of Cosmetic Procedures
OPTIONAL ENDORSEMENTS
FORM # DESCRIPTION
G -121487-B Amendment to Certificate
G -121504-C General Liability Form
PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC
TO YOUR STATE AND YOUR POLICY PERIOD.
For NJ residents:
For KY residents:
For WV residents:
For FL residents:
The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance
Guaranty Association.
The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement
Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which
includes charges at a municipality and/or county level.
The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge.
The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association
- 2012 Regular Assessment.
Form#:G-141241-B (03/2010)
Named Insured:Adelaida Campbell
Master Policy#: 188711433 Policy#: 0299197210
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