HomeMy WebLinkAbout20163182.tiffCOLORADO
Office of Children,
Youth Er Families
n
/z
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
day of
ael 2
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between Weld County Department of Social/Human Services, PO Box A. Greeley, Colorado,
80632, hereinafter called "County" and Imagine!, 1400 Dixon Ave, Lafayette, CO 80026, hereinafter
called "contractor"
THIS AGREEMENT:
Shall include all children placed by Weld County Department of Social/Human Services and
placed with Imagine!.
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
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John w ,chenl per, Gove,n Blcha. Exer.utive Director
2016-3182
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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
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John W. Hickentooper, Governor ; Reggie Bicha, Executive Director
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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 treatment/service plan, and those persons shall acknowledge their responsibility by
signing the treatment/service plan.
SECTION II: LEGAL STATUS AND AUTHORIZATIONS:
I. 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:
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John W. Htckenlooper, Governor I Reggie Bicha, Executive Director
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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;
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John W. Hickentooper. Governor Reggie Bich&, Executive Director
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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: CONTRACTOR 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 ofchildren i ldren 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
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John W. Hickentooper, Governor 1 Reggie Bicha, Executive Director
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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
departments.
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 MMIS 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 by
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
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John W. Hickenlooper. Governor I Reggie Bicha, Executive Director
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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 county as
the child maintenance or room and board. Any payment to the foster parent in excess of
the child maintenance or room and board amount shall 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 by a
Child Placement Agency, Contractor agrees that each foster parent has received State
training in how to use and apply the reasonable and prudent parent standard to decisions
involving the participation of the child or youth in age or developmentally appropriate
activities.
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:
1. Determine eligibility of the children under this Agreement for placement and medical
coverage. Medicaid rules and regulations shall govern determination of Medicaid
eligibility.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Human Services.
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 of Human Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. If this agreement covers an initial placement for a child, the Contractor may receive a
clothing allowance in accordance with State Department rules.
6. Monitor children's progress in accordance with the treatment/family services plan and
the requirements of Colorado Department of Human Services rules and provide
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,
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John W. Ffickentooper, Governor I Reggie Bicha, Executive Director
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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 to
recover or withhold subsequent payments as defined in rules.
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 ofContractor shall he 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, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing availability
of State of Colorado, county. and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to
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bin in W. Nickeritooper, Governor I Reggie Bicha, Executive Director
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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 costs for clients
enrolled in PRTF, Rat and CHRP programs shall be submitted to the
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.
h.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.
(I) The Contractor must have in place a double entry accounting system and all
financial transactions must he posted to this system. Financial statements,
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John W. Hickentooper. Governor I Reggie Bicha, Executive Director
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prepared from information provided by this system, shall be presented in
conformity with U.S. generally accepted accounting principles (GAAP). The
Contractor must also have adequate time keeping and cost allocation systems to
allocate salary cost and indirect cost to appropriate cost centers. Books and
records of the Contractor shall be subject, at any reasonable time, to inspection,
audit or copying by appropriate Federal, State or county personnel, or such
independent auditors or accountants as may be designated by these personnel.
(2) All b !ling by the contractor must be in a format approved by the fiscal agent
or county. Contractors must bill the fiscal agent and county at least once a
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 oftheir financial statements by an independent certified
public accountant. Contractors with tc'tal annual expenditures less than $100,000
may submit an audit as described above or may submit compiled or reviewed
financial statements. prepared in accordance with generally accepted accounting
principles. If the Contractor is a government agency that has an independent audit
done by another agency of that government, its audited financial statements,
prepared in accordance with generally accepted accounting principles for state
and local governments meet this requirement. The audited, compiled or reviewed
financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy
provided to the Colorado Department of Human Services (Attn: Administrator
for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180
days after the contractor's fiscal year end. The audited financial statements and
supplementary information defined in regulation for various agencies shall be
presented as described in Section VI, B (1), above and must contain sufficient
detail to provide evidence of financial accountability under the terms of this
contract and controlling. state regul itions. Contractors that are a subsidiary of a
parent organization must submit separate financial statements for the subsidiary
that detail each of the Contractor's facilities and/or programs that provide services
for the Colorado Department of Fluman Services and also must provide a
reconciliation of these financial statements to the consolidated financial
statements of the organization as a whole. When applicable, the Contractor must
comply with the audit reouir•ements found in the Single Audit Act of 1984 and the
Single Audit Act Amendments of $ 996 and V. S. Office of Management and
Budget (OMB) Circular A -1 33 , Audits of States, Local Governments, and Non-
Profil. Organizations including subsequent revisions, and appropriate audit and
financial reporting requirements as defined it State laws. rules, and regulations.
(4) 1fContractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted. If the contractor is a CPA. then sanctions of the contractor may occur
for failure to submit.
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Amer u : f. Hi ickenlooper . Governor Reggie Bicha, Executive Director
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(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 shall
be submitted to the State Department's Audit Division for approval within 4
months of the date of the audit.
(7) Failure to comply with any of these requirements, including items on the
addendum is, justification to the County to impose fiscal sanctions, penalties, or
cancel the contract.
6. In the event this ccntract is terminated. final payment to the Contractor may be
withheld at the discretion of the Cau'ty until final audit. Incorrect payments to the
Contractor due to omission, error. fraud, or misuse of funds shall be recovered from the
Contractor ; ither by deduction 4com subsequent pay ments under this contract or other
contracts between the County and the Ccntractor or by the County, as a debt due to both
the State of Colorado. the Colorado Department of Human Services and the County. The
waiver of any violation shall not he construed as a waiver of any other or subsequent
violation of this contract or appropriate statutes and regulations.
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written z boN e
COUNTY:
ATTEST: (/,, J took BOARD OF COUNTY COMMISSIONERS
Weld u.ty Clerk to the oard WLI D COUNTY, COLORADO
By:
Deput Clerk tc��� '.'fit' - ' /4) �� Mike Freeman, Chair
1',75 Sherman Stn_ t, : ftour
OCT 12 2016
Imagine!
!400 Dixon Ave
Lafayette. CO 80026
htractor's (or designee's) Signature
and Date
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Rc4,gie f;1cha Exer_utiw-• Direetor
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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 entitled, "Agreement
to Purchase Out -of -Home Placement Services SS23A, attached hereto, by and between the Board
of County Commissioners of Weld County. on behalf of the Weld County Department of Human
Services," hereinafter referred to as. "County," and Imagine!, hereinafter referred to as,
"Contractor."
I . County and Contractor agree that a child specific Needs Based Care Assessment,
designated in this exhibit, shal' be used to determine levels of care for each child placed
with Contractor.
2. County agrees to purchase and Contractor a€.rees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated in this exhibit, for children
placed within the CPA identified as Provider ID#21369. These services will be for
children who have been deemed eligible tbr social services under the statutes, rules and
regulations of the State of Colorado.
3. If a child is deemed eligible for the Children's Habilitation Residential Program (CHRP)
waiver, Contractor agrees to accept the assessed waiver service rate billable through the
MM IS system and the federal SSI rate bi I lab'e through the County.
4. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility. including hospitalization. Bed hold requests must
have prior written authorization from County's Department Administrator before
payment will be release to provider.
5. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be
furnished by the Contractor under this contract for facilities that provide sex offender
treatment.
6. Any additional costs for specia'ized services. which include, but are not limited to;
polygraph teits. plethysmoQr iphs. and urinalysis screens, which are not provided within
the negotiated provider rate, will need to be authorized, in writing by County, prior to the
service being performed. Any payment for specialized services not authorized in writing
will be denied.
7. Contractor agrees to have appropriate personnel available to attend or participate in
Family ingagement, Team Decision Making meetings, or court hearings. Contractor
shall he notified by County stag of the dates and times attendance is requested.
8. Contractor agrees to cooperate with any vendors hired by the County to shorten the
duration of placement.
Exhibit to the Ss?.; Revised 6/2016
9. Contractor agrees to have physical examinations completed within 14 days and dental
examinations completed within 8 weeks of the child being placed with Contractor. All
documentation of these examinations shall be forward to Count` .
10. Contractor agrees to arrange a lull evaluation of an individualized Educational Plan (°EP)
for youth designated as a Special Education Student every 3 years and coordinate reviews
every year. If the HT is due while the child is in placement, the Contractor shall
complete or obtain a completed !FP. A copy will then be forwarded to the County.
11. Children in Psychiatric Residential Treatment Facilities, Residential Child Care Facilities
and Child Placement Agencies are not eligible to receive clothing allowances as outlined
in the Weld County Department of Human Services Policy and Procedure Manual.
12. County shall have access to Contractor's financial records as they relate to this Agreement
for purposes of audit. Such records shall be complete and available for audit 90 days after
final payment hereunder and shall he ret?.fined and available for audit purposes for at least
five years after final payment hereunder.
13. Time is of the essence in each and all of the provisions of this Agreement.
14. Neither party to this Agreement shall he 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 be: on: its reasonable control. including but not limited to Acts
of God. fires. strikes, war. flood, earthquakes or Governmental actions.
15. Any notice required to he given wider this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
16. This Agreement and the provision of sere ices hereunder shall be subject to the laws of
Colorado and he in accordance with the po!icies, procedures, and practices of County.
17. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform sen ices of the same or similar nature.
18. Contract Professional certifies. warrants, and agrees that it does not knowingly employ or
contract with an illegal aalcn who will percorm workunder this contract. Contract
Professional w ill confirm the employment c*li 2ibi!ity of all employees who are newly
hired for employment in the United States to perform work under this Agreement, through
participation in the F. -Verify program or the State of Colorado program established
pursuant to C.R.S. §8--17.5-1(12(51(c). Contract Professional shall not knowingly employ
or contract with an illegal alien to pertbrm work under this Agreement or enter into a
contract with a subcontractor that fails to certify with Contract Professional that the
subcontractor shall not knowin Jly employ or contract with an illegal alien to perform
work a nci 'r this A. greemen _ . Contract Prot' ssional shall not use E -Verify Program or State
of Colorado prograr proxdures to undertake pre -employment screening or job applicants
while this Agreement is being performed. If Contract Professional obtains actual
knowledge that a subcontractor performing w'H under the public contract for services
knowingly employs or cont.rrets with 2.r illegal alien Contract Professional shall notify the
subcontractor and County within thr ee (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 e subcontractor does not stop employing or contracting with
Exhibit to the SS2 A Revised 6/2016
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. IfC'ontract Professional participates in the State of
Colorado program, Contract Professional shall, within twenty days after hiring an new
employee to perform work under the contract, affirm that Contract Professional has
examined the legal work status c1snch 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 Co lorado pr. gram. If Contract Professional fails to comply
with any requirement of this _provision or ofC.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 consecinentu.I damage'
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 at tiny individual natural person eighteen (18) years of age or
older is lawfu:ly present in the United States pursuant to C.R.S. § 24-76.5-103(4), if such
individual applies for public benefits provided tinder 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 cne of the forms of identification required by
C.R.S. § 24-'6 S-101, et seq., ane (el shall produce one of the forms of identification
required by C.R.S. § 21-76 5-'03 nrior to the effective date of the contract.
19. Contractor assures and certifies the it and its principals:
a. Are not presently debarred, suspended, proposed for debarment, and declared
ine!i iihle or voluntar f v excluded from covered transactions by a federal
department or agency:
b. Have not, within a three-year Period of preceding this Agreement, been convicted
of or had a civil _judhzrner rendered iga&nst them for commission of fraud or a
criminal offense in connection with obtaining. attempting to obtain, or performing
a public (federal. mate', or local) transaction or contract under a public transaction;
violation of federal or state ant itru it statutes or commission of embezzlement,
then. for` r` , bribery, falsification or destruction of records, making false
statements, or receiving stolen property:
c. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (tedcrz.3! . state. or local) with commission of any of the offenses
ent.'rnerated in paragraph On abo .e:
d. Have net within a three-year period preceding this Agreement, had one or more
public transactions ( state_ and local) terminated for cause or default.
20. In additifnn to terminating thk M;r:ern ntaccGrdance with the provisions of the
attached Agreement. the Cc'urt:. ma:. exerci,c the following remedial actions County find
and determine that Contractor has !.uhstantial ly failed to satisfy the scope of work found in
Exhibit to the SS
> RCN 'sett 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 fallowing:
a. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
b. Deny payment or recc"er reimbursement for those services or deliverables which
[gave not been performed and A hich due to circumstances caused by Contractor
cannot be performed or if performed would he of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to Court'
c. Recover from Contractor any incorrect payment to Contractor due to omission,
error. fraud. and/or defalcation hy deducting from subsequent payments under this
kgreement, or other T. reements between County and Contractor, or as a debt to
County. or otherwise as provided hsv law.
I
2
I 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 u 'dersigned parties or'he&r assignees, and nothing contained in this
Agreement shall the or vllc ►« ?n? chilli or right of action V‘ hatsoever by any other person
not included in this Agreement. It is tLte e' press Intention of the undersigned parties that
any entity other thar the undersigned parties or their assignees receiving services or
benefits under this Agreement shall he an incidental beneficiary only.
22. No portion of this Agreement shall he deemed to constitute a waiver of any immunity
including those provided the Colorado Governmental Immunity Act §§24-10-101 et
seq., as applicable now or hereafter amended_ that the parties or their officers or
employees iva} possess nor shall any portion of this Agreement be deemed to have
created a duty of care that did not previously. e \ ist with respect to any person not a party
to this Agreermwt. The part s hereto acknowledge and agree that no part of this
Agreement is intended to circumvent or replace such immunities.
23. Contractor shall .,rornntly notif) County in Vie event in which it is a party defendant or
respondent in a cag=e. which involves serv;:car provided under the agreement. The
Contractor, within five (0) calenO ar dny s tier being served with a summons, complaint,
or other pleading wb!ch has beer tikcd it ari:,federal or state court or administrative
agenc', shall d r live r ccpies ot, such lid.%cunit'nit s) to the County Director. The term
"litigation" includes an a.ss&grment for the henetir of creditors. and filings in bankruptcy,
reorganizations and/or foreclosure.
24. Any amens"eats Ifs rrodiiicati{ins to this agreement shall be in writing signed by both
parties.
25. Financial ohligaL i' m' Crtit. (' y inty payable after the current fiscal year are contingent
upon #un:is for that purpose hang •rppropri.zted. budgeted and otherwise made available.
Execution ofthi<, 4greemem b:,- County does not create an obligation on the part of
County to expend funds not otherwise appropriated in each succeeding year.
Exhibit to the SS''.;.A
I Revised 6/2016
26. Contractor agrees that it is an independent Contractor and that Contractor's officers,
agents or employees will not become employees of County, nor entitled to any employee
benefits from County as a result of the execution of this Agreement. Contractor shall
perform its duties hereunder as an independent Contractor. Contractor shall be solely
responsible for its acts and those of its agents and employees for all acts performed
pursuant to this Agreement. Contractor, its employees and agents are not entitled to
unemployment insurance or workers' compensation benefits through County and County
shall not pay f - Or or nth: rxi s: rrov ide such co% rage for Contractor or any of its agents or
employees.
27. County reserves the right to require the Contract)" to provide a certificate of insurance,
policy, or other proof of insurance at its sole discretion.
Exhibit to the SS23A 5 Revised 6/2016
Needs Based Care Assessment
NBC
Answers
closest
(NEEDS
rating
to
the
BASED
for
following
this
child.
CARE
questions
The
ASSESSMENT)
following
will
determine
seven
(7)
the
questions
NBC
Care
are
Payment.
mutually
For
exclusive.
each
question
below
please
select
the
P1.
in
How
Therapy;
the
often
treatment
Medical
does
the
plan?
child
"Treatment:
require
transportation
Family
Visitation;
by
the
Extraordinary
t«ster
care
Educational
provider
for
Needs;
the
following:
etc..
as outlined
Select
One
P2.
sessions?
How
often
is the
foster
care
provider
required
to participate
in child's
therapy
or counseling
Select
One
P3.
conjunction
How much
time
with
is isle
a regular
Intr.
sue!
or
special
'C4UItCL! A' WWI %
education plan?
ilt; at twine tutu; us at JLillAli %Altil L. citiid
in
Select
One
P4.
How
often
does
the
child
require
special
and
extensive involvement
by the provider
in scheduling
Select
One
and
monitoring
of
time
and/or activities
and/or crisis management?
How
much
time
is the
provider required
p
to assist the
child
because impairments
he,eausc, of im
airmcnts beyond age.
Select
One
appropriate
needs
with
feeding. bathing.
grooming. ph)
sisal.
andior
occupational
therapy?
Al.
How
**please
or
more
oven
group
than
Note:
is C'PA.'(
The
one
,
( ase !Management
County foster child
level
is
may
with the
,. .
be assessed
same
pros icier.
scrap) ►
on a combined basis if
a sibling
Select
One
T1.
flow
often
are
thera•N
services needed
to address
child's
s indis
idual
needs
er
NBC
assessment?
Select
One
NBC (NEEDS
BASED
CARE ASSESSMENT)
— Behavioral
Assessment
Assessment
Are2s' I
Comment:
Rating:
I]
Aggression/Cruelty
to . \,, icn.tis
L
Select
One
-- _ -- _ -- _ _ _
`
❑
Verbal
or
Physical
"1
hreatening
Select
One
Destructive
of
Prgpert)/Eire Setting
Select
One
Stealing
Select
One
_
- _
❑
Self
-injurious
E�o.
� ,.,.:
Select
One..
`
❑
Substance
Abuse
,
Select
One
_ _
_
_
❑
Presence
of
Psychiatric Symptoms/Conditions
Select
One
(�
Enuresis/Encopresis
Select
One
_
❑
Runaway
Select
One
_
Sexual
Offenses
Select
One
Inappropriate
Sexual
Behavior
Select
One
Disruptive
Behavior
Select
One
(l
Delinquent
Behm ior
Select
One
❑
Depressive
-like,
f.L, t., Ski,
Select
One
- - - - -
Medical
Needs
.. t l
f- eondit:t.).1 ;s rated _.:i.:\ ere-.
please
Select
One
❑
the
Medically
fragile
NBC)
complete
(I
Emancipation
Select
One
Eating
Problems
Select
One
_
Boundary
Issues
Select
One
1 1
Requires
Night Care
Select
One
❑
Education
Select
One
-
a
Involvement
with Child's
; aAI`
Select
One
Exhibit A to the tiff_ 3A
Res ised 6/2014
Needs Based Care Assessment
WELD COUNTY OHS
Requested Services from Agency
Please indicate the services that are requested for this child.
The following information w ill he reflected on the child specific contract.
(Please he specific)
T^
_ _ _ __
Adoption
Services.
U
Medical Services
Ej
Other:
NA
I
❑
Doctor/Dentist
Appointment
pTx
ointment Coordination
Pro\ ider
agrees to «ork
with
family
Medication
Ev
tee tier
❑
❑
al
uation (not covered
under
service)
Therapeutic
Services
funded
through
♦lediclid
Fee for
Medication
Monitoring
❑
r--,
`-'
Service:
(TRCCF)
Individual
Therapy
_
(1
Nursing
Services/Coordination
Ej
❑
Group
Therapy
❑
Physician
Services/Coordination
T~
_ _
Interactive
Group
Therapy
Occupational
Therapy
❑
•
Family
therapy
❑
Speech
P
Therapy
Therapy
_ — -
—7
[J
Psy
chological
Testing
Child
Find
(_
Pharmacological
Management
�,
Other:
_
❑
Treatment
not
funded h' Medicaid
f� ec' for Serv'ce:
�
Education:
174
Home
Based
Inters
ention
_
On
-Grounds
School
❑
MST
Multi
-Systemic Therapy
Coordinate
Assessment
for
Special
Education
❑
Offense
Specific
Treatment
❑
Public
School
Attendance
Occupational
Therapy
��
Drug
and
Alcohol
Treatment
'
Speech
Therapy
❑
Attend
Special
Education
Meetings
l Trine
Analysis/Drug
screenin&r
Breathaly
rcr
_i
Other:
❑
❑
Sexual
Abuse
Victimii r inn i'rcatmen'
_
.
Visitation
Coordination
Independent
Living
Skills
I
raining'
frs■
Monitor
phone
calls
and correspondence
Anger
Management
7
T
Transportation
for
family/parent/child
visits
❑
Behavior
Modification
tier\ ices
Other:
ri
Behavioral
Assessment
_1
Other:
❑
Recreation Services
-
Interpreter
Services
■
`
Case Management
....1l
I
Other:
❑
Attend
Court
T-learin s
Transportation:
To incIude_
O
Other:
__ __ _
Levels of ('are:
Provider Level:
Case Management Level:
Therapy Level:
Date Staffed:
Participants:
Comments:
Exhibit A to the `s.
Revised 6/2014
Needs Based Care Rate Table
Weld County Department of Human Service
(Effective 7/01/2015)
I
SERVICE
1.VEl,
OF
NI
(1111,1)
AIM
1i.
NANCE
RESPITE
RESPI'I
E
, �DMINISTR
MAI\TE\..
r AT1R
M_
I•,
F.
ADMINISTRATIVE
SERVICES
�rir...
MEDICAL
NEEDS
wwrM..Tw./...
Daily
Rate
+w.rx+wn... _ ...... .......
..I.KK.r.
W.-.w. "..n.n+....•..
NAM,MM.M1w yu ...-.x W.,` .'
l...evrel
Daily
Rate
Daily
Rate
Daily
Rate
Daily
Rate
r
(
Maintenance
ounty
•
Rate
Basic
'a
'V
F
Age
Age 1i-14...$18.81
Age I
0-10...$17.0
�- :.
I .',20.09
1,
\ '-,
h •`Aa
2y!
$12.35
No crisis intervention, Minimal
CPA involvement. one face -to-
tact: visit with child per month..
A
Not
needed
under
$0.00
Medicaid.
or cover
$3.45
1
$_0.56
$15.1
Minimal crisis
aec.xlcu, one
per month
contacts
face-to-face
with
intervention
child,
per month
as
visit
2-3
I ,^
•a aXyy
a
. .
Regularly
therapy
hours/month.
$5.14
Scheduled
up
to
4
I
'/z
$21.q')Si
- - -
......... ............
1
$4.97
2
.....r
.-��.
¶2.7.42
—
' ! `. Occasional
$.66 I. L > needed_
`. :4 with child,
�
two
crisis
$19.20
intervention as
face-to-face visits
2-3 contacts per
month
t
therapy
month
Weekly
group
with
$10.28
scheduled
5-8
therapy.
4
hours
hours
a
of
$20.91
2 '4
¶30.85
$.66
1/
,
S'4
2'
440
°4°�� -
= i
:
_-^$6f,sessions,
..�,,,,
Ongoing
g
?JCeekly
e visits
coo,
g
‘k itll
diiiation
$71
crisis
child,
sery
fit
intervention
tact -to
and intensive
ot• multiple
icres.k
-taco
as
,x
. -N
'
f.z
.
.--.rl
Regularly
weekly.
more
i.e.
9-12
family
$15.42
than
hours/monthly.
can
therapy,
scheduled
multiple
I
include
person.
for
-
,t73
$t�
3 1/2i
,,
S37.6t) S.66 i $24.34
-
Negotiated
ongregate are
Drop
o,-
Down
$41.11$.66
Ongoing
needed.
level of
i CPA involvement
provider
contacts
$26.05
crisis
which
case management
and
per week
intervention
includes
2-3
with
face
minimum.
child
-to
high
face
and
as
and
Negotiated
... _
.........
amen-....._..
%ssessmerit/
Emergency
Level Rate
°
$27.42
h -., ,
` `
01.20
Exhibit A to the SS23A
Revised 6/20 14
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