HomeMy WebLinkAbout20162963.tiffCOLORADO
Office of Children,
Youth & Families
Department or Human Services
SS -23A Agreement to Purchase
Revised 10/15
AGREEMENT TO PURCHASE
OUT -OF -HOME PLACEMENT
SERVICES SS23A
CHILD PLACEMENT AGENCY SERVICES (CPA)
CHILD HABILITATION RESIDENTIAL PROGRAM (CHRP)
GROUP HOME/GROUP CENTER CARE
INDEPENDENT LIVING
PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF)
RESIDENTIAL CHILD CARE FACILITY (RCCF)
RESIDENTIAL DRUG/ALCOHOL PROGRAM
SHELTER CARE
SUBSIDIZED ADOPTION
TRANSITION/HOME BASED AFTER -CARE (RCCF)
OTHER (DESCRIBE): _
THIS IS AN AGREEMENT, made this p2/ day of
between Weld County Department of Social/Human Services, PO Box A, Greeley, Colorado,
80632, hereinafter called "County" and Family Resource Network, 5360 N. Academy Blvd., # 130,
Colorado Springs, CO 80918, hereinafter called "contractor"
THIS AGREEMENT:
Shall include all children placed by Weld County Department of Social/Human Services and
placed with Family Resource Network.
A child specific addendum, identifying individual service needs, must be completed and
attached to supplement this agreement for each child being served by the facility. If this
is a CPA placement, the child specific addendum should also address how administrative
services will be provided in the event the child is placed for adoption in a foster home
supervised by the CPA.
WHEREAS, the Colorado State Department of Human Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of
individuals through its agents, County Departments of Social/Human Services, and
WHEREAS, the County is authorized to purchase certain services for eligible children
under State Department rules, and
2016-2963
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-866-5536 www.colorado.gov/cdhs
eAr7fAi-e/,'Ll? John W. Hickenloope Governor ( Reggie icha, Executive Director
�i, (���•�-ems 1���1
9- of/— /4'
WHEREAS, the County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child
Care Facility, certified Psychiatric Residential Treatment Facility, or meets the
requirements for other licensed service types.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings
the County and the Contractor agree as follows:
1. This Agreement shall be in force from the date of the agreement,
July 1, 2016, until the end of the Colorado fiscal year, June 30, 2017.
Any child may be removed from the facility prior to the end of the fiscal
year by the county department.
2. This Agreement may be renewed only by entering into a new written
Agreement such as this Agreement signed by the authorized
representatives of the parties. Except as otherwise provided above, either
party shall have the right to terminate this contract by giving the other
party thirty (30) days notice by registered mail, return receipt requested. If
notice is so given, this contract shall terminate on the expiration of the
thirty (30) days or until the eligible child(ren) can be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease, but the
parties shall not be released from the duty to perform their obligations up
to the date of termination.
3. This Agreement is in lieu of and supersedes all prior agreements between
the parties hereto and relating to the care and services herein described.
SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED:
1. The total rate of payment for care and services under this Agreement shall not exceed:
the established rate for the PRTF; for CPA placements, the negotiated rate or the
approved vendor rate; for RCCF placements, the established Fee -for -Service rate and the
negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon
service proposal rate. The total rate of payment for care and services for other service
types will be as negotiated between the County and the Contractor. Medicaid rules shall
govern activities to be covered in the daily rate paid to PRTFs.
The amount paid for purchased care and services for less than a full month will be based
upon the daily rate.
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1, F (12 CCR 2509-5).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-866-5536 www.colorado.gov/cdhs
John W. Hickenlooper, Governor I Reggie Bicha, Executive Director
2
completed If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County has responsibility for the decision to return the child to the facility,
with input from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the Family Service Plan / Individual Plan of
Care.
5. Any transportation costs to be incurred on behalf of a child in placement, which are to
be borne by persons, or agencies, which are not a party to this contract, shall be specified
in the tre,atment/service plan, and those persons shall acknowledge their responsibility by
signing the treatment/service plan.
SECTION II: LEGAL STATUS AND AUTHORIZATIONS:
1. Such permission as is held by the County is hereby granted to the Contractor to
authorize routine or emergency medical and dental treatment except that:
a. Medical or dental care shall be provided by personnel duly licensed by law as
required by the State of Colorado. It is mutually understood hereto that hospital
expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other
unusual expenses are not included in the monthly rate. The cost of any items not
covered by Medicaid will be negotiated between County and Contractor. Medicaid
rules shall govern activities to be covered in the daily rate paid to PRTFs.
2. County and Contractor shall insure that the child(ren) is enrolled in the Early and
Periodic Screening, Diagnosis and Treatment Program.
3. It is agreed and permission is granted for the child(ren) to participate in planned
recreational and social activities of Contractor, including supervised off grounds
excursions and extended trips within the State, provided that Contractor has written
permission from County and legal guardian for any trips out of Colorado for any reason
and any planned absence from the facility of over seven (7) days within a consecutive
30- day period. Such written permission may be in the treatment/service plan. Further,
Contractor and County will also secure, where possible, permission from parents or
guardians of the child placed with the Contractor. Any planned absence of more than 24
hours for children placed in a PRTF is not Medicaid reimbursable.
4. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status which comes to their attention.
SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS
REPORTS:
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-866-5536 www.colorado.gov/cdhs
John W. Hickenlooper, Governor I Reggie Bicha, Executive Director
3
1. County and Contractor agree and understand that the reasons for referral, which
necessitate purchasing services for children are specified in the attached child specific
addendum and Family Services Plan. Any other relevant information concerning these
children that does not necessitate purchasing services is also included in the addendum.
2. County and Contractor shall develop an initial plan that addresses the immediate
and/or emergency needs of the child within 72 hours of admission for children in RCCFs
or group homes except PRTF. County and Contractor shall formulate an initial individual
plan of care within 14 calendar days after admission for children in RCCFs or group
homes except PRTF. The placement date is that date noted in the attached child specific
addendum included with this contract. The Child's Family Service Plan may be utilized
as an Individual Plan of Care for this purpose for facilities. Modifications to this plan
shall be agreed to in writing on the plan or as a supplemental document.
3. County and Contractor shall formulate an initial individual plan of care for children in
PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care
must be completed by the multidisciplinary team within 14 calendar days from the
placement date. The placement date is that date noted in the attached child specific
addendum included with this contract. Modifications to this plan shall be agreed to in
writing on the plan or as a supplemental document.
4. The individual plan of care shall be goal oriented and time -limited and shall:
a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with
clinical and other needs including the child's presenting problems, physical
health, emotional status, behavior, support system in the community, available
resources, and discharge plan.
b. Include specific goals and measurable objectives, expected dates of
achievement, specific discharge and transitional/after-care and follow up services
criteria to be met for termination of treatment.
c. Specify the type, frequency, and duration of clinical therapy services,
rehabilitation services, medication management, emergency services, initial
assessment, documented treatment modifications, and other services determined
to be necessary to meet the child's specific goals.
d. Specify that all therapeutic services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
e. Identify the provision of, or the referral for, services other than RCCF services
and shall document any court ordered treatment including identifying the agency
responsible for providing the court ordered treatment.
f Anticipated living arrangement for the child at the date of discharge;
g. Anticipated educational arrangement for the child at the time of discharge;
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-8b6-SS36 www.cotorado.gov/cdhs OV. _Co
John W. Hickenlooper, Governor I Reggie Bicha, Executive Director
:tee:
ii�l
4
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than
PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term
and long-term goals have been achieved or not achieved. These parties shall provide the
County with written reports which address changes to the child's physical condition,
psychological and social functioning, changes in the child's family situation, educational
progress, significant incidents or disciplinary actions, and progress made to achieve goals
specified in the treatment plan. Further, the Contractor agrees to sequence reports to be
received by the County 15 calendar days prior to judicial or administrative hearings or
reviews when provided with 30 calendar days advance notice of such dates by County.
6. Every 14 days, PRTFs shall provide the County with written reports which address
changes to the child's physical condition, psychological and social functioning, changes
in the child's family situation, educational progress, significant incidents or disciplinary
actions, and progress made to achieve goals specified in the treatment plan.
SECTION IV: CON IRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Human Services, the Colorado Department of Health Care Policy and Financing (if
appropriate), the State of Colorado and any applicable federal laws and regulations, as
such, which may be amended from time to time, and shall be binding on Contractor and
control any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law and rule.
3. Not charge any fees to children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub -contract
without the express written approval of the Director of the County Department or his/her
appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act
of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security
Act of 1975 as revised, and provide confidentiality of information concerning the child in
compliance with the Health Insurance Portability and Accountability Act (HIPAA).
6. Maintain during the term of this Agreement a liability insurance policy of at least
$25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability,
$150,000 for injury and/or damage to any one person, and $600,000 for total injuries
arising from any one accident.
7. Maintain during the terms of this Agreement an insurance policy or a fidelity bond in
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-866-5536 www.colorado.govlcdhs
'�f-;)
John W. Hickentoo
Fer, Governor i Reggie Bicha, Executive Director ; f
5
an amount deemed sufficient by the county, covering the activities of any of its officers,
agents, or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
8. Indemnify County, Colorado Department of Human Services, Colorado Department of
Health Care Policy & Financing, and the State of Colorado against any and loss against
all claims and actions based upon or arising out of damage or injury, including death, to
persons or property caused or sustained in connection with the performance of this
contract or by conditions created thereby, or based upon any violations of any statute,
ordinance, or regulation and the defense of any such claims or actions.
Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county
�,
9. In regards to University of Colorado contractors only, the contractor shall be
responsible for its own wrongful or negligent acts or omissions or those of its officers,
agents, or employees while performing their professional duties to the full extent allowed
by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or
waiver of the application of the Colorado Governmental Immunity Act set forth in §24-
10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the
University of Colorado, its employees or agents under this Agreement.
10. Maintain service program records, fiscal records, documentation and other records,
which will sufficiently and properly reflect all direct and indirect costs of any nature
incurred in the performance of this Agreement. The above shall be subject at all
reasonable times to inspection, review or audit by federal, Colorado Department of
Human Services, Colorado Department of Health Care Policy & Financing, or county
personnel, and other persons authorized in writing by the Executive Director of the
Colorado Department of Human Services_
11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the
initial home study, the SAFE study update, annual certification updates and related
materials when requested by the County within fourteen working days of the request. At
all other times the Contractor shall make home studies and related materials available to
the County for review, at a location agreed upon by the County and the Contractor,
during regular business hours.
12. Bill the County for services rendered, using the required form. This form is to be
mailed to the County by the last day of the month of care. Billings for PRTFs shall be
made to the NMS System only. Billings for RCCF fee -for —service and CHRP shall be
made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and
other contractor types shall be made to the County only. Contractor will not be paid b
the county when billing is not received by the County within 30 calendar days following
the billing due date.
13. Attend and participate in Administrative Reviews for children in placement with the
Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-866-5536 www.colorado.gov/cdhs
John W. Hickentooper, Governor i Reggie Bicha, Executive Director
6
encourage children over the age of twelve to attend their Administrative Reviews.
Participation may be in person or by teleconference.
14. The Contractor shall pay the foster parent the amount agreed upon with the coup as
the child maintenance or room and board. An n'
y payment
the child maintenance or room and board amount
m untshall be treated as income to the foster
parent.
15. The Contractor shall have the on -site presence of at least one (1) official who has
received State training in how to use and apply the reasonable and prudent parent
standard and who, with respect to any child or youth placed at the Contractor's facility,is
designated to be the caregiver authorized to apply the reasonable and prudent parent
standard to decisions involving the participation of the child or youth in age or
developmentally -appropriate activities. In the case of a Foster Care Home certified b a
Child Placement Agency, Contractor agrees that each foster y
ved State
training in how to use and apply the reasonable and prudent parent standard
parent has �to decisions
involving the participation of the child or youth in age or developmentally appropriate
riate
p
16. Contractor shall ensure that each foster
parent or caregiver authorized to apply the
reasonable and prudent
parent standard receives sufficient, ongoing training to continue
to use and apply the reasonable and prudent parent standard for each child or youth
placed in the foster home or facility.
SECTION V: COUNTY SHALL:
r :
1. Determine eligibility of the children under this Agreement for placement
coverage. Medicaid rules and regulations shall govern determination of Medicaidmedical
eligibility.
Department of Human Services.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate when billing is submitted as described in Section IV, Number 10
(above).
4. Abide by all the rules and regulations of the Colorado Department
federal rules and regulations and the laws of the State of Colorado, any Human
�� Services,
amended from time to time.y
5. If this agreement covers an initial placement for a child, the Contractor may receive
clothing allowance in accordance with State Department rules. a
6. Monitor children's progress in accordance with the treatment/family
the requirements of Colorado Department of Human Services rules and provide plan and
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-366-5536 www.cotorado.gov/cdhs
John W. Hickentooper, Governor t Reggie Bicha, Executive Director
7
consultation to Contractor in relation to the services purchased under this Agreement.
7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled
review.
8. Involve Contractor in planning for the child and give the Contractor a copy of the
Family Services Plan at time of placement or as soon as completed and when updated or
revised.
9 The County shall seek recovery from the RCCF, CPA or other contractor type for any
non -Medicaid payment amounts that have been misused as defined in rules. The County
may withhold subsequent payments to recover any funds misused by the RCCF, CPA or
other contractor type. The County shall seek recovery of any remaining funds as a debt
due the County for the benefit of the state. The RCCF or CPA may appeal the decision
recover or withhold subsequent payments as defined in rules. to
10. The County shall identify the amount agreed upon with the Contractor to be paid to
the foster parent for the child's room and board. Such amount will be the same as shown
in Trails for the child's maintenance.
11. Reimbursement rates that are negotiated between the County and the Contractor shall
be for allowable costs in one or more of four primary components: child maintenance
administrative services, administrative maintenance, and treatment. Contractor type will
determine which of these four components will be included in the reimbursement rate.
12. The County shall provide the Contractor with a copy of the policy that identifies
activities that providers trained in the reasonable and prudent parent standard may
approve, and identifies activities that require County department approval.
13. The County shall require that the person(s) authorized to apply the reasonable and
prudent parent standard, including each foster parent, will complete State training
specific to the reasonable and prudent parent standard and will receive ongoing training
as necessary in order., to meet the needs of each child or youth, and to use and apply the
reasonable and prudent parent standard.
SECTION VI: GENERAL PROVISIONS:
1. The Parties to this Agreement intend that the relationship between them, contemplated
by this Agreement is that of employer independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of the County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub -contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado, coup
whether in whole or in part, is subject to and contingent upon the contyinu geavail bilieral ��
of State of Colorado, county, and federal funds for the purpose thereof ty
3. It is agreed that if, after investigation, it is shown that reasonable care was given to
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-866-5536 www.cotorado.gov/cdhs
John W. Hickenlooper, Governor ! Reggie Bicha, Executive Director
8
guard and protect personal items brought to Contractor by the children, Contractor will be
released from responsibility for loss or damage to such personal items.
4. This Agreement is intended to be applied in conjunction with the child specific
addendum and family services plan as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other amendment
hereto shall have any force or affect whatsoever, unless embodied herein in writing. No
subsequent notation, renewal, addition, deletion, or other amendment hereto shall have
any force or effect unless embodied as a part of this written Agreement. This section shall
not be construed as either prohibiting the periodic amending of the family services plan
or appending a county designed addendum to this agreement.
5. The contract shall permit the State Department to monitor service program, fiscal and
other records sufficiently to assure the purchase of services in this Agreement are carried
out for the benefit of the aforementioned client. Monitoring may occur through review of
program reports, on -site visits where applicable and other contracts as deemed necessary.
The Contractor understands that the State Department may provide consultation to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
a. All reimbursement requests shall be submitted to and approved by the
appropriate County staff. Reimbursement for placement services shall be paid
from the date of admission up to, but not including, the day of discharge.
Furthermore, Medicaid payments for PRTF and CHRP placements are permitted
on the day of discharge in compliance with regulations promulgated by the
Colorado Department of Health Care Policy and Finance. Fee for Service will be
reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to
funds encumbered in this contract and shall also include Medicaid funds for
PRTF and RCCF therapeutic services and CHRP services paid by the
Department of Health Care Policy and Financing. Payment for placement
services will not be provided for clients on "runaway" status unless the County
has previously approved it. Reimbursement requests for therapy
enrolled in PRTF, RCCF, and CHIRP programs shall be submitted costs clients
Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal
Agent. The Contractor shall forward copies of such billings to the County on a
monthly basis.
In the event that a Contractor receives payment for a per diem discharge day,
regardless of funding source, the Contractor shall refund those dollars forthwith.
b. The purpose of these requirements is to provide minimum assurance that the
Contractor has adequate accounting and budgeting information available to allow
management to maintain a financially viable enterprise and to demonstrate
financial accountability to the county departments of human/social services and
Colorado Department of Human Services for the use of public funds.
(1) The Contractor must have in place a double entry accounting system and all
financial transactions must be posted to this system. Financial statements,
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-866-5536 www.colorado.gov/cdhs
John W. Hickenlooper, Governor l Reggie Bicha, Executive Director
9
prepared from information provided by this system, shall be presented in
conformity with U.S. generally accepted accounting principles G
Contractor must also have adequate time keeping and cost allocatiosystems e
allocate salary cost and indirect cost to appropriate cost centers. Books
ook and to
records of the Contractor shall be subject, at any reasonable time, to inspection,
audit or copying by appropriate Federal, State or count
y personnel, or such
independent auditors or accountants as may be designated by these personnel.
(2) All billing by the contractor must be in a format approved by the fiscal
or county. Contractors must bill the fiscal agent and county at least once a agent
month. Contractors may bill twice a month, on the 15th and last day of the
month, for services rendered. Bills will be returned unpaid if the bills do not
conform to the approved format or the documentation is inadequate.
(3) All Contractors whose total annual expenditures are $100,000 or more shall
submit an annual audit of their financial statements by an independent certified
public accountant. Contractors with total annual expenditures less than $100,000
may submit an audit as described above or may submit compiled or reviewed
00
financial statements, prepared in accordance with generally accepted accounting
principles. If the Contractor is a government agency that has an independent audit
ug
done by another agency of that government, its audited financial
prepared in accordance with generally accepted accounting statements,
and local governments meet this requirement. The audited, compiled or reviewed
principles for state
financial statements of PRTFs, RCCFs, and CPAs must be completed and
provided to the Colorado Department of Human a copy
for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) wig
(Attn: Administrator
days after the contractor's fiscal year end. The audited financial statements in 180
supplementary information defined in regulation for various agencies shall and
presented as described in Section VI, B 1 be
detail to provide evidence of financial accountability and must contain sufficient
contract and controlling state regulations. Contractors that are a under the subsidi srms of ubsidiary
s
parent organization must submit separate financial statement for the subsidiary
that detail each of the Contractor's facilities and/or programs that provides viY
for the Colorado Department of Human Services and also must provide a
reconciliation of these financial statements to the consolidated services
statements of the organization as a financial
comply with the audit requirements found in the Sn ingle Audiplicable, t Act he of 4rmust
Single Audit Act Amendments of 1996 and U. S. Office of 1984 and the
Budget (OMB) Circular A-133, Audits of States, Local Governments, Band Non -
Profit Organizations including subsequent revisions, and appropriate audit and
financial reporting requirements as defined in State laws, rules, and r
egulations.
(4) If Contractors do not submit their annual audit or refuse to disclose fin
information regarding the operation of the program atancsc
Agent may withhold payment until the audit and/or requested informatiomely manner, n Fiscal
submitted. If the contractor is a CPA, then sanctions of the c is
for failure to submit. contractor may occur
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-866-5536 www.colorado.gov/cdhs
John W. Hickentooper, Governor i Reggie Bicha, Executive Director
10
(5) In cases where documentation does not exist to support audit information or
services provided, contractor will be required to repay all funds received for
which documentation does not exist.
(6) In cases where audit deficiencies are noted, a plan of corrective action
be submitted to the State Department's Audit Division for approval within4
shall
months of the date of the audit. pp 4
(7) Failure to comply with any of these requirements,County including items on the
cancel the contract. to impose fiscal sanctions, penalties, or
6. In the event this contract is terminated, final withheld at the discretion of the County payment to the Contractor may be
Contractor due to omission, error, fraud, ormisuseonal ffunds shait. ll Incorrectrecovered paymentto the
Contractor either by deduction from subsequent payment under this contract
from the
contract between the County and the Contractor byor the County, trbctor other
the State of Colorado, the Colorado De ty, as a debt due to both
waiver of any violation shall not be construed as a alive of any othan Services er or tu subsequent
violation of this contract or appropriateCounty. The
statutes and regulations.
WHEREFORE, the parties have herein set their hands and affixed their
seals the day and
date first written above.
COUNTY:
ATTEST:
Weld
By:
Jdo;tA
Clerk to the oard
Deputy : lerk to th
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
t o
Mike Freeman, Chair
SEP 21 2016
NTRACTOR:
Family Resource Network
5360 N. Academy Blvd., # 130
Colorado Springs, CO 80918
By:
Contractor's or designee's) Signature
and Date
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-866-5536 www.colorado.gov/c
John W. Hickenlooper, Governor dhs
I Reggie Bicha, Executive Director
11
EXHIBIT A to the SS23A
Additional Provisions for the Agreement to Purchase
Out -of -Home Placement Services SS23A
For the Purchase of
Child Placement Agency Services
The following additional provisions of this Exhibit apply to the agreement e
to Purchase Out -of -Home Placement Services SS23A, attached hereto, by and
entitled, "Agreement
of County Commissioners of Weld County, between the Board
oSf ," hereinafter referred to as, "County,"on behalf of the Weld County Department
referred to as, "Contractor." and Family Resource Networ, hereinafter
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated in this exhibit, shall be used to determine levels of care for each placed
with Contractor. child child
2. County agrees to purchase and Contractor agrees to provide the care and s
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate ofpayment eservices, which
indicated by the Needs Based Carate Table, ldesignated
for each level of service, as
placed within the CPA identified as Provider 1D#1508602. 1n this exhibit, vc for children
children who have been deemed eligible for social services under Theseservices
ssttatuute , will berules and
regulations of the State of Colorado.s, and
3. If a child is deemed eligible for the Children's Habilitation Residential Program
waiver, Contractor agrees to accept the assessed waiver service rate billable thr (CHRP)
e
NMS system and the federal SSI rate billable through the County. ough the
4. All bed hold authorizations and payment are subject to a ?
temporary absence from a facility, day maximum for a child's
tY, including hospitalization. Bed hold requests must
have prior written authorization from County's Department Administrator
payment will be release to provider. before
5. A minimum of one polygraph test per Colorado fiscal year, if needed by
child, will be
furnished by the Contractor under this contract for facilities that provide sex offender
offender
6. Any additional costs for specialized services, which include, but are not limited to;
polygraph tests, plethysmographs, and urinalysis screens, which are not provided within
the negotiated provider rate, will need to be authorized, � wri •
service being performed Any payment for specialized services of authorized
bCounty, prior to the
will be denied.
will
7. Contractor agrees to have appropriate personnel available to attend or
Family Engagement, Team Decision Making meetings, or court hearings
earin srticipate in
shall be notified by County staff of the dates and times attendance is r qu Contractor
8. Contractor agrees to cooperate with any vendors hired b � � ested.
duration of placement. Y e County to shorten the
Exhibit to the SS23A
Revised 6/2016
9. Contractor agrees to have physical examinations com leted
tal
examinations com leted within 8 weeks -p--- within 14 days
documentation of these examinations shall be forward to County.of the child being placed Contractor. and nAll
10. Contractor agrees to arrange a full evaluation of an Individualized
for youth designated as a Special Educational Plan OEp
every year. If the IEP is due while the child isucation ina placent ment, 3 )
complete or obtain a is dieted l A copy every years and coordinate reviews
will then be forwarded to the County
11. Children in Psychiatric Residential Treatment Facilities,Residential
and Child Placement Agencies are not eligible to receive clothin
Child Care Facilities
in the Weld County Department of Human Services Policy an d Procedure Manual.
12. County shall have access to Contractor's financial records as
for purposes of audit. Such records shall be complete and available eyrelate to this Agreement
final payment hereunder and shall be retained and available for for audit 90 for least
five years after final days after
payment hereunder. audit purposes at least
13. Time is of the essence in each and all of the provisions of thi
14. Neither s Agreement.
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
failure is due to any cause beyond its reasonable control, including
of God, fires, dstrikes, war, flood a this Agreement, where suchdm
> arthquakes or Governmentg but not limited to Acts
15. An al actions.
y notice require{ to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other parry at that party's address as s
16. This Agreement and the provision of services hereon fated above.
der shall be res subject to the laws of
Colorado and be in accordance with the policies, procedu
17. This A > an d practices of County.
greement is nonexclusive and County
may engage or use other contractors or
same or similar nature.
18. Contract Professional certifies
contract with an illegal alien who will perform work under this contract.
Professional will confirm the emplo men d gr� that it does not knowingly em to
w Contract employ or
hired for employment in the United States to perform lwork uof all nder
this
employees who are newly
participation in the E -Verify program er this A
established
pursuant a to C.R.S. § or the State of Colorado program Agreement, through
8-17.5-102(5)(c). Contract Professional shall not knowingly
or contract with an illegal alien to perform work under this Agreement
contract with a subcontractor that fails to certify employ
subcontractor shall not knowingly with Contract Professional thatlthe nto a
under this Agreement. employ or contract with an illegal alien to
workof Colorado program
Contract Professional shall not use E -Verify Pro perform
p gam procedures to undertake pre -employment while this Agreement is being p p Yment screening gram or State
performed. If Contract Professional obtainsactual
ob applicants
knowledge that a subcontractor performer
knowingly employs or contracts with an illegal alien Contracwork under the t
Professional
contract shall r snotify
subcontractor and County ct Professional notify the
subcontractor
knowledge within three (3) days that Contract Professional
that a subcontractor is employing or contracting has e actual
terminate the subcontract if a subcontractor does not stop employing
nth an illegal alien and shall
or contracting with
Exhibit to the SS23A
Revised 6/2016
the illegal alien within three (3)
�� of receiving notice. Contract Professional shall not
terminate the contract if within
establish that the subcontractor has not knowingly employed or con
days the subcontractor provides information to
alien. Contract Professional shall comply with reasonable requests made
an illegalsof an investigation, undertaken pursuant to C.RS. §8-17.5-102 5
o
Department of Labor and Employment. in the course of
p yment. If Contract Professionalparticipates the th
Colorado program, Contract Professional shall, within twen r hi in the new
of
employee to perform work under the contract, affirm that Contract Profess'
examined the legal work status of such employee,� days after hiring an new
and not altered or falsified the identification documents for such . Contract has
retained file copies of the documents,
Professional shall deliver to County,en employees.
the legal work status of such employee, and shall notcom lrized affirmation all on that it has examined
requirements of the State of Colorado program. comply with all of the other
with any requirement of this provision or of C.RS §8-17.5-101 et sentract q.,
fails to comply
terminate this Agreement for breach, and if so terminated, Contract Professional
liable for actual and orbs �1�, County' may
consequential damages. sronal shall be
Except where exempted by federal law and except as provided in C.RS _
if Contract Professional receives federal or state funds under the contract,
Professional must confirm that any individual natural person en§ 24 76.S-103(3),
olderProfessional
is lawfully 18 years
o
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 ( ) of age or
operates as a sole proprietor, it hereby swears or affirms under pen penalty
o ft r that it: (a) is a citizen of the United States or is otherwise lawfully nperjury United that it: pursuant to federal law, (b) shall produce one of the forms of identification the States
C.RS. § 24-76.5-101, et seq., and (c) shall produce one of the forms
required by C.R.S. required by
q § 24-76.5-103 prior to the effective date of the controf act.
identification
19. Contractor assures and certifies that it and its principals:
a. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency;
b. Have not, within a three-year period of preceding this Agreement,
of or had a civil judgment rendered against them for commission of fraud
criminal offense in connection with obtaining, attempting been convicted
goorn
a public (federal, state, or local) transaction or contractundera public transaction;
tain, or a�ing
violation of federal or state antitrust statutes or commission of embezzle
theft, fore
forgery, bribery, falsification or destruction of records, making falseent,
statements, or receiving stolen property;
c. Are not presently indicted for or otherwise criminally or civilly charged
government entity (federal, state, or local) with commission of an by a
enumerated in paragraph (B) above; 3' of the offenses
d. Have not within a three-year period preceding this Agreement,
public transactions (federal, state, and local) terminatd r cuse or def r more
20. In addition to terminating this A cult.
attached AAgreement, in accordance with the provisions of the
Agreement, the County may exercise the following remedial actions Coun
tyfind
and determine that Contractor has substantially failed to satisfy the scope of work found in
Exhibit to the SS23A
3
Revised 6/2016
the Agreement, any Exhibit, the child specific addendum SS23B, or the Needs Based Care
Addendum. 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
include, but are not limited to, any one or more of the following:
a. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
b. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
c. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
21. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees,
Agreement shall give or allow any claim or right
ighof action whatsoever by any other erson
not included in this Agreement. It is the express intention of the undersigned p
any entity other than the undersigned parties or their assignees receiving srvices or ies that
benefits under this Agreement shall be an incidental beneficiary only.
22. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
including those provided by the Colorado Governmental Immunity Act §§24.10-101 et
seq., as applicable now or hereafter amended, that the parties or their officers or
employees may possess, nor shall any
created a duty of care that did not previously lexist with respecton of this an ent be person deonot to have
to this Agreement. Thees p any a party
Agreement is intended to circumvent or replaereto ce such imme unities.
and that no part of this
23. Contractor shall promptly notify County in the event in which it is a party
respondent in a case, which involves services provided under the agreementefThdeant or
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 County Director. The term
"litigation" includes an assignment for the benefit of creditors, and filings in bankrupts
reorganizations and/or foreclosure. y,
24. Any amendments or modifications to this agreement shall be in writing signed by both
parties.
25. Financial obligations of the County payable after the current fiscal year are contingent
upon funds for that purpose being appropriated, budgeted and otherwise made available.
Execution of this Agreement by County does not create an obligation on the part of
County to expend funds not otherwise appropriated in each succeeding year.
�xhibit to the SS23A
4
Revised 6/2016
26. Contractor agrees that it is an independent Contractor and that Contractor's offic
agents or employees will not become employees of County,
ers,
benefits from County as a result of the execution of this Agreement. Contractor shall
loyee
perform its duties hereunder as an independent Contractor. Contractor shall be solely
responsible for its acts and those of its agents and employees for all acts performed
pursuant to this Agreement. Contractor, its employees and agents are not entitled
unemployment insurance or workers' compensation benefits through County and County
shall not pay for or otherwise provide such coverage for Contractor or any of its agents or
employees.
27. County reserves the right to require the Contractor to provide a certificate of insurance,
policy, or other proof of insurance at its sole discretion.
ibit to the SS23A
5
Revised 6/2016
Needs Based Care Assessment
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. F
nsatin, for this child. The folquestions
will . P1. How often does the child re seven 7 . uestions are mutual, or each question below please select the
q�e trans
Therapy; Medical Treatment; Family p°�t1°n by the foster care provider for the following:
in the treatment ,Ian? Visitation; Extraordinary Educational Needs; etc., as outlined
P2.
Haw often is the foster ater care provider req
uired to participate in child's therapy or counseling
P3. How much time
is
the provider required to intervene at home and/or at school with the child in
con unction with a re ar or ,ecial education Ian?
P4. How often does the child require special and extensive involvement b
and
monito . , . of time and/or activities and/or crisis mana + ement? the rovider in scheduling
PS. How much time is the provider required to assist the child because of
annr�riaLe needs with feeding, g bathing, grooming,occupational
beyond aaP
physical, and/or occupational therapy?� Al. How often is CPA/County case manage
""Please Note: The Case Manmay assessed went required? (Does not include therapy)
group agement level be on a
combined basis if a sibling
or more than one Conn foster child is with the same rovider.
T1. How often are Thera.
services needed to address child's individual needs , •r NBC assessment?
NBC (NEEDS BASED CARE ASSESSMENT) - Behavioral Assessment Areas- Assessment
_+ ession/Cruel to Animals
Verbal or Ph sical Threatenin
Destructive of Pro, /Fire Settin
Stealth
Self ,urious Behavior
Substance Abuse
Presence of Ps chiatric S ,toms/Conditions
Enuresis/Enco,resis
Runawa
Sexual Offenses
Ina ro,hate Sexual Behavior
Disru,tive Behavior
Delin, uent Behavior
Depressive -like Behavior
Medical Needs - (If condition is rated "severe", please
complete the Medically fragile NBC)
Emancipation
Eatin_ Problems
Bounds Issues
Re. wires Ni , t Care
Education
Comment:
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Exhibit A to the SS23A
6
Revised 6/2014
7
3
Ado i lion Services
Other: NA
Provider agrees to work with family
Needs Based Care Assessment
WELD COUNTY DHS
Requested Services from Agency
Please indicate the services that are requested for this child.
The following information will be reflected on the child specific contract.
(Please be specific)
Therapeutic Services funded through Medicaid Fee for
Service: ' CCF)
Individual Thera. r
Grou. Them
Interactive Gro . Thera
Fanul Thera
P cholo . 'cal Test
Pharmacolo: 'cal Management
Treatment not funded b Medicaid Fee for Service:
Home Based Intervention
MST Multi -S stemic Thera.
Offense S . cific Treatment
Drug and Alcohol Treatment
Sexual Abuse Victimization i • • r
Inde � ' ndent Livin�ahon Treatment
Skills Tra..'..
er Management
Behavior Modification Services
Behavioral Assessment
Recreation Services
Case Mana ement
Attend Court He.
Trans ortation: To include:
3Is of Care:
Provider Level:
Case Management Level:
Therapy Level:
Date Staffed:
'ipants:
ents:
0
0
11
0
Irma
to
mug
i
0
cv
0
■
rum
Medical Services
Doctor/Dentist A ointment Coordination
Medication Evaluation (not covered under fee for
service
Medication Monitoring
Nursin_ Services/Coordination
Ph sician Services/Coordination
Occ • • tional Thera.
S.eech Thera
Child Find
Other:
Education:
On -Grounds School
Coordinate Assessment for S . ecial Education
Public School Attendance
Occu.: tional Thera.
S.•ech Them
Attend S. •cial Education Meetin.s
Other:
Visitation Coordination
Monitor .hone calls and cone .ondence
Tr.. .. rtation for famil /. arent/child visits
Other:
Other:
Other:
Exhibit A to the SS23A
7
Revised 6/2014
Hello