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Home My WebLink About20162039.tiffD 52,81 CONTRACT AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND POLARIS PARTNERS, LLC (CORE) This Agreement Amendment, made and entered into c' 74 day o 2016, by and between the Board of Weld County Commissioners, on behalf of the Weld ounty Department of Human Services, hereinafter referred to as the "Department", and Polaris Partners, LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Home -Based Intensive Services (Aftercare Wraparound Services) (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2015-0493, approved on October 6, 2014. 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 ended on May 31, 2015. • The Original Agreement was renewed for the term of June 1, 2015 -May 31, 2016. The Agreement Amendment is identified by the Weld County Clerk to the Board of County Commissioners as document No. 2015-1853, approved on June 24, 2015. • The Amendment, together with the Original Agreement, constitutes the entire understanding between the parties. The following change is hereby made to the Contract Documents: 1. Term This agreement shall become effective on June 1, 2014, upon proper execution of this Agreement and shall expire May 31, 2017, unless sooner terminated as provided herein. 2. Exhibit B, Scope of Services, is hereby amended as attached. 3. Exhibit C, Payment Schedule, is hereby amended as attached. • All other terms and conditions of the Original Agreement remain unchanged. 2016-2039 0-0644-1- t• /L IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY ATTEST: d�@titiv�'C y Weld • unty Clerk to the Board By: BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO TML Mike Freeman, Chair JUN 2 7 2016 olaris Partners, LLC 1136 East Stuart Street, Suite 2240 Fort Collins, Colorado 80525 (970) 576-1717 By: Date: r Damond Dotson, Ph.D., L FT - Partner - co EXHIBIT B SCOPE OF SERVICES 1. Contractor will provide Home Based Intensive Services, in the form of evidenced -based Wraparound principles and Cognitive Behavioral Therapy (CBT) techniques, to individuals and families, as referred by the Department. 2. Services are available as follows: • In -Home Wraparound (Therapist and Facilitator) • In -Home Wraparound (Therapist Only) — Utilized when youth or family require in -home therapy only. • In -Home Wraparound (Facilitator Only) — Utilized when youth or family require facilitation of team meetings, education on parenting skills, assistance in accessing community resources, and case management services. 2. Services include: • Therapist and/or Wraparound Facilitator interaction with youth and family in the home • Intensive individual and family therapy in the home • Parent education and support • Assessment of strengths, needs and cultural discovery • Risk assessment • Natural support through team development • Crisis/relapse prevention planning • Youth is connected with community resources as appropriate • Monthly team meetings and Care Plan updates • Court reports and appearances as necessary • Assistance with Community Service requirements • Life skills/independent living skill development 3. The goal of the Wraparound services is to bring the residential program to the youth's home and community by providing needed support and services that the Wraparound team has agreed upon. The intent of the services is to solidify the work begun in residential placement and empower families to implement what is needed for their own unique circumstances, ultimately allowing for self-sufficiency. 4. Contractor is an approved Medicaid provider. Contractor will bill Medicaid for all Medicaid -eligible services for any client referred by the Department. 5. Contractor 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. 6. 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. 7. 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 8. 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. 9. 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. 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. 2 EXHIBIT C 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, 2017. 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 $125.00/Hour (In -home Therapy. Charged only when Medicaid is not an available funding source.) $75.00/Hour (Wraparound Facilitator) $50.00/Hour (Hourly travel reimbursement outside 20 -mile radius of 1136 East Stuart Street, Suite 2240, Fort Collins, Colorado 80525.) 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. b. For one-time services, proof of services rendered shall be receipt of the completed product. 1 c. For Monitored Sobriety services, proof of services rendered shall be the test result. 2 POLAPAR-01 KVANDENENGEL ACORO CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/2/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Howard Insurance Agency, Inc. 6900 Wisconsin Ave Suite 450 Chevy Chase, MD 20815 INSURED Polaris Partners Counseling & Counseling LLC P.O. Box 426 Loveland, CO 80539 CONTACT NAME: PHONE FAX (A/C, No, Ext): (301 ) 652-2500 (A/C, No): (301) 652-2530 ADDRESS: INFO@HOWARD-INSURANCE.COM INSURER(S) AFFORDING COVERAGE INSURER A: Hartford Insurance Group INSURER B: Beazley Insurance Company Inc. INSURER C : INSURER D : INSURER E : INSURER F : NAIC # COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE X OCCUR 42SBAUH0128 12/05/2015 12/05/2016 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRO - POLICY JECT LOC OTHER GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ $ $ 4,000,000 4,000,000 AUTOMOBILE LIABILITY A ANY AUTO 42SBAUH0128 ALL OWNED SCHEDULED AUTOS AUTOS NONOWNED X HIRED AUTOS X AUTO -S COMBINED OBI tED) SINGLE LIMIT a a 12/05/2015 12/05/2016 BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) $ $ $ $ 2,000,000 UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DED RETENTION $ EACH OCCURRENCE AGGREGATE $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N A ANY OFFICER/MEMBER/EXCLUDED? ECUTIVE- -) NIA 42WECCR9690 PER OTH- STATUTE ER 12/05/2015 12/05/2016 E.L. EACH ACCIDENT $ 1,000,000 (Mandatory in NH) If yes, describe under E . DISEASE - EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E . DISEASE - POLICY LIMIT $ 1,000,000 B Data Breach/Cyber BBRSL0713 12/05/2015 12/05/2016 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) THIS CERTIFICATE IS ISSUED FOR INFORMATIONAL PURPOSES ONLY. CERTIFICATE HOLDER CANCELLATION INFORMATIONAL PURPOSES ONLY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD HEALTHCARE PROVIDERS SERVICE CNAORGANIZATION PURCHASING GROUP HPSO Producer Branch Prefix 018098 970 HPG Named Insured and Address: Polaris Partners, LLC 816 Snowberry St Longmont, CO 80503-9430 Certificate of In5ttrance OCCURENCE POLICY FORM Policy Number 0615479691 Medical Specialty: Licensed Professional Counselor Firm Excludes Cosmetic Procedures Healthcare Providers Service Organization" Print Date: 9/17/2015 Policy Period from 11/01/15 to 11/01/16 at 12:01 AM Standard Time Program Administered by: Healthcare Providers Service Organization 159 E. County Line Road Hatboro, PA 19040-1218 1-888-288-3534 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 Defendant Expense Benefit Deposition Representation Assault Includes Workplace Violence Counseling Medical Payments First Aid Damage to Property of Others Enterprise Privacy Protection - Claims Made Retroactive Date: 11/01/2015 (Defense inside limits) Workplace Liability Workplace Liability Fire & Water Legal Liability Total: $ 2,794.00 $ 5,000,000 aggregate $ 25,000 per proceeding $ 25.000 aggregate $ 1,000 per day limit $ 25,000 aggregate $ 10,000 per deposition $ 10,000 aggregate S 25,000 per incident $ 25,000 aggregate $ 25,000 per person $ 100,000 aggregate $ 10,000 per incident $ 10,000 aggregate $ 10,000 per incident $ 10,000 aggregate $ 25,000 per incident $ 25,000 aggregate Included in Professional Liability Limit shown above Included in the PL limit shown above subject to $150,000 aggregate sublimit Base Premium $2,794.00 Policy Forms & Endorsements(Please see attached list for a general description of many common policy forms and endorsements.) G -121500-D GSL15565 CNA81753 CNA79575 G -121503-C GSL17101 CNA81758 Chairman of the Board G -141241-B (03/2010) G -121501-C GSL13424 CNA79516 G -145184-A GSL13425 G -121486-B G -147292-A CNA80052 G -123828-B fik\i\4-A Secretary Coverage Change Date: GSL15564 G -123846-005 (05) 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.ln 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: 411) HEALTHCARE PROVIDERS PROFESSIONAL LIABILITY COVERAGE PART ENDORSEMENT Additional Insured - Person or Entity In consideration of the premium paid, and subject to the Professional Liability limit of liability shown on the certificate of insurance, it is agreed that the PROFESSIONAL LIABILITY COVERAGE PART is amended as follows: The person or entity named below (the "additional insured") is an insured under this Coverage Part but only as respects its liability for your medical incidents and solely to the extent that: 1. a professional liability claim is made against you and the additional insured; and 2. in any ensuing litigation arising out of such claim, you and the additional insured remain as co- defendants. In no event is there any coverage provided under this policy for a medical incident that is the direct liability of the additional insured. Additional Insured: Weld Adolescent Resources Inc & The State of Colorado DHS 315 N orth 11 th Ave Greely, CO 80634 This endorsement is a part of your policy and takes effect on the effective date of your policy, unless another effective date is shown below. All other provisions of the policy remain unchanged. Must Be Completed ENDT. NO. 01 POLICY NO. 0615479691 Complete Only When This Endorsement Is Not Prepared with the Policy Or Is Not to be Effective with the Policy ISSUED TO ENDORSEMENT EFFECTIVE DATE Polaris Partners, LLC 11/01/2015 G -121486-B (07/2001) Page 1 of 1 Hello