HomeMy WebLinkAboutC21-279 EC Core Service PlanDocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31DEA7B8C7C4
�r :7)
ICDqHS
Office of Children,
Youth & Families
Division of Child Welfare
CORE SERVICES PROGRAM
SECOND YEAR OF A THREE-YEAR PLAN
SFY 2019 - 2020
SFY 2020 - 2021
SFY 2021 - 2022
FOR
EAGLE COUNTY
Please complete signature page, all corresponding Core Services
Plan and budget pages, and then submit the original hard copy
for approval.
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31DEA7B8C7C4
REQUEST FOR STATE APPROVAL OF PLAN
Since this is the second year of the three-year Core Services Plan, all signatures on this page are
required.
This Core Services Plan is hereby submitted for Eagle County[Indicate county name(s) and lead county
if this is a multi -county plan], for the period contract years June 1, 2021, through May 31, 2022 fiscal
years July 1, 2021, through June 30, 2022. The Plan includes the following:
• Completed "Statement of Assurances";
• Completed program description of each proposed "County Designed Service";
• Completed "Information on Fees' form;
• Completed "Overhead Cost" form (Optional);
• Completed "State Board Summary";
• Completed "100% Funding Summary" form; and
• Completed "Final Budget Page".
This Core Services Program Plan has been developed in accordance with State Department of Human
Services rules and is hereby submitted to the Colorado Department of Human Services, Division of
Child Welfare for approval. if the enclosed proposed Core Services Program Plan is approved, the Plan
will be administered in conformity with its provisions and the provisions of State Department rules.
The person who will act as primary contact person for the Core Services Plan is Kendra Kleinschmidt and
can be reached at telephone number 970-471-4679 and email at Kendra. Kleinschmidt@eaglecounty.us.
If two or more counties propose this plan, the required signatures below are to be completed by each
county, as appropriate. Please attach an additional signature page as needed.
Megan Burch1 Digitally signed Megan Burch
Date: 2021.07.13 0:52:41-06'00'
Signature, DIRECTOR, COUNTY DEPARTMENT OF HUMAN/SOCIAL SERVICES DATE
j er4 64. L4��7� r3 a oa./
Sign at , CHAIR, PLACEMENT ALTERNATIVES QOAMISSION DATE
"DocuSigned by:
� 8/17/2021
Signature, CHAIR, ARDLOFECOUNTY COMMISSIONERS DATE
Please check here if your county does not have a Placement Alternative Commission:
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
CORE SERVICES
STATEMENT OF ASSURANCES
Eagle County(ies) assures that, upon approval of the Core Services Program Plan the following will be
adhered to in the implementation of the Program:
Core Services Assurances:
• Operation will conform to the provisions of the Plan;
• Operation will conform to State rules;
• Core Services Program Services, provided or purchased, will be accessible to children and
their families who meet the eligibility criteria set forth in Rule Manual Volume 7, at 7.303;
• Operation will not discriminate against any individual on the basis of race, sex, national
origin, religion, age or mental/physical disability who applies for or receives services
through the Core Services program;
• Services will recognize and support cultural and religious background and customs of
children and their families;
• Out-of-state travel will not be paid for with Core Services funds;
• All forms used in the completion of the Core Services Plan will be State prescribed or State
approved forms;
• Core FTE/Personal Services costs authorized for reimbursement by the State Department
will be used only to provide the direct delivery of Core Services;
• The purchase of services will be in conformity with State purchase of service rules including
contract form, content, and monitoring requirements;
• Core Services Program expenditures will not be reimbursed when the expenditures may be
reimbursed by some other source. (Set forth in Rule Manual Volume 7, at 7.414,B);
• Information regarding services purchased or provided will be reported to the State
Department for program, statistical and financial purposes;
• All providers of Core Services (through purchase of service contracts) must be registered
with the Colorado Department of Regulatory Agencies (DORA). The provision of Life Skills is
the only exception to this mandate;
• County staff are responsible for monitoring their Program provider payments and for
ensuring the county and providers are following all statutory and regulatory requirements;
• All Core Services are made available, based on need of each child/youth/family; and
• All contracts for services using Core Services Program funding will include all of the required
language of the attached contract template.
3
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7138C7C4
CORE SERVICES TO BE PROVIDED/PURCHASED
List below "County Designed Service" that will be provided/purchased. Please indicate which, if any,
of the County Designed Service are provided through the Evidenced Based Services to Adolescents
earmarked funding:
• Family Engagement Meetings
• Trauma Informed Services, Nontraditional Therapies
• Therapeutic Supervised Visits
• Evidence based home visiting program - Healthy Families Vail Valley
Eagle County will not utilize the allocation ($5,340) for Adolescent Evidence Based services.
Program Area Three - PA3 Services - Prevention/Intervention Services
If your county submitted a Program Area Three (PA3) Plan last fiscal year, and you wish to continue
providing PA3 services using Core Services Program funding, please check the box below;
X Yes, our county wishes to continue offering PA3 services using Core Services Program funding.
If your county has not submitted a Program Area Three (PA3) Plan, and you wish to provide PA3
services, please complete and submit the PA3 Plan Addendum attached.
Fundine for Evidenced Based Services to Adolescents
If the county received funding for evidenced based services to adolescents, and is requesting the
funding to continue to receive the same funding for the same expansion or creation of the evidenced
based county designed program to adolescents, please indicate that above, as well as on the Core Plan
under County Designed.
• Multi -Systemic Therapy (MST)
• Multi -Systemic Therapy - Contingency Management (MST -CM)
MST is an evidence -based, intensive, in -home treatment for youth who are at risk for out of home
placement.
MST -CM is an evidence -based, intensive, in -home treatment for youth who are at risk for out of home
placement and involved in delinquent behavior and substance use or substance abuse.
See pages 14-15 for more information about this county designed service.
4
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
CORE SERVICES COUNTY DESIGNED SERVICE
Service Name: Family Engagement Meetings
Optional services approved as a part of the county's Core Services Plan are approved on an annual
basis. For a County Designed Service to be extended beyond one year, this portion of the plan must be
submitted and approved annually by the State Department.
Given that County Designed programs are not standardized across counties, it is important to provide
detailed information as outlined below. The information listed below is to be completed for each
County Designed Service and included in the County(ies)' Core Services Program Plan.
1. Describe the service and components of the service; define the goals of the program.
Eagle County Department of Human Services (ECDHS) recognizes the importance of involving
family members, their identified support systems, and professional partners also working with
the family in decision making about children and youth who need protection or care. The
Family Engagement program at ECDHS actively collaborates with family members and their
formal and informal support systems to create and implement plans that support the safety,
permanency and well-being of children and youth.
Family engagement meetings utilize the Consultation and Information Sharing Framework. Risk
and goal statements are used to help family members and their support systems understand the
Department's perspective. The conversation during family engagement meetings is focused on
the three following areas: family strengths, danger/harm and complicating/risk areas, and next
steps. Action plans are created from the next steps category. The meeting attendees plan
around issues that are identified in order to keep children in the home whenever possible or
return children to their home as soon as possible.
2. Indicate if a new Trails service detail is necessary for this County Designed Program or that the
service detail is already an option in Trails.
Service detail for this County Designed Program is already available in Trails.
3. Define the eligible population to be served.
The eligible population includes children and youth between the ages of 0-18 years and their
families who have open child welfare assessments or cases.
5
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31DEA7B8C7C4
4. Define the time frame of the service.
ECDHS requires Family Engagement Meetings take place:
• During child welfare assessments when families score "High" on the Colorado risk
assessment (for both High Risk Assessments Et Family Assessment Response)
• During assessments when a safety concern has been identified and a safety plan
implemented (for both High Risk Assessments Et Family Assessment Response)
• At the time of child welfare case opening (within seven business days)
• Every 3 months during a child welfare case when a child in the family is placed in
out of home care
• Every 6 months during a child welfare case when the family remains intact
• At the time of child welfare case closure
5. Define the workload standard for the program:
• number of cases per worker:
Trained employees of Eagle County DHS or contracted service providers facilitate family
engagement meetings.
• number of workers for the program:
There are no specific workers for the family engagement program, but currently ECDHS
has five (5) trained employees to facilitate family engagement meetings.
• worker to supervisor ratio:
At ECDHS in the Division of Children, Family Et Adult Services, the number of workers to
supervisors is four to one.
6. Define the staff qualifications for the service, e.g., minimum caseworker III or equivalent, see
7.303.17 for guidelines.
ECDHS employees and contracted service providers who facilitate family engagement meetings
will have attended and successfully completed a family engagement meeting facilitation training.
7. Define the performance indicators that will be achieved by the service, see 7.303.18.
The family engagement service prevents out of home placement for children and adolescents and
secures permanency for those in out of home placement. Additionally, the family engagement
service program is a 2Gen approach to services and engagement for children and their parents
identifying a plan for them to make progress together.
6
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
8 Identify the service provider.
This is a direct service provided by ECDHS employees or various contracted service providers.
9. Define the rate of payment (e.g., $100.00 per session/episode).
ECDHS employees:
• Caseworker(s)- 10% of FTE
• Payroll worker- 5% of FTE
• Supervisor(s)- 10% of FTE
• Manager- 5% of FTE
• Contracted service providers- $75/hour
7
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31DEA7B8C7C4
CORE SERVICES COUNTY DESIGNED SERVICE
Service Name: Trauma Informed Services, nontraditional therapies
Optional services approved as a part of the County's Core Services Plan are approved on an annual
basis. For a County Designed Service to be extended beyond one year, this portion of the plan must be
submitted and approved annually by the State Department.
Given that County Designed programs are not standardized across counties, it is important to provide
detailed information as outlined below. The information listed below is to be completed for each
County Designed Service and included in the County(ies)' Core Services Program Plan.
1. Describe the service and components of the service; define the goals of the program:
Eagle County Department of Human Services (ECDHS) uses specialized therapies to address
grief, loss and trauma experienced by children and families in the child welfare system. These
specialized therapies use an integrative healing therapeutic approach and may be very helpful
when traditional talk therapy has not led to improved symptomatology. Trauma Informed
Services may include:
• Music therapy
• Yoga therapy
• Play therapy
• Art therapy
• Dance therapy
• Equine Assisted therapy
• Talk therapy utilizing trauma informed evidence based practices
2. Indicate if a new Trails service detail is necessary for this County Designed Program or that the
service detail is already an option in Trails:
Service detail is already an option in Trails
3. Define the eligible population to be served:
The population for trauma informed practices, nontraditional therapies includes children, youth
(ages 0-18) and their parents, legal guardians or caregivers who have an open child welfare case
and who meet the CORE Services Eligibility Criteria.
4. Define the time frame of the service:
Children, youth and families are eligible for this service twice a month or as recommended by the
service provider.
8
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31DEA7B8C7C4
5. Define the workload standard for the program.
• Identify the number of cases per worker:
N/A, purchased service
• Identify the number of workers for the program:
N/A, purchased service
• Identify the number of workers to supervisor ratio:
N/A, purchased service
6. Define the staff qualifications for the service, e.g., minimum caseworker III or equivalent, see
7.303.17 for guidelines:
ECDHS employees do not provide this service. Contracted service providers will meet the Core
Services requirements by having a bachelor's degree or higher in the human services field, such
as counseling or social work and they will have current licensure through DORA.
7. Define the performance indicators that will be achieved by the service, see 7.303.18:
The performance indicators achieved by this service will often be determined in the treatment
plan written and agreed upon by the contracted service provider, the family member and the
ECDHS Caseworker. An example of a performance indicator is increased parent competency:
parent will show the ability to provide care for their child(ren) as evidenced by providing proper
discipline.
8. Identify the service provider:
Various providers
9. Define the rate of payment:
$90/hour in office services and $100/hour for in home/off site/bilingual services
9
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31DEA7B8C7C4
CORE SERVICES COUNTY DESIGNED SERVICE
Service Name: Therapeutic Supervised Visitation
Optional services approved as a part of the County's Core Services Plan are approved on an annual
basis. For a County Designed Service to be extended beyond one year, this portion of the plan must be
submitted and approved annually by the State Department.
Given that County Designed programs are not standardized across counties, it is important to provide
detailed information as outlined below. The information listed below is to be completed for each
County Designed Service and included in the County's Core Services Program Plan.
1.Describe the service and components of the service; define the goals of the program:
Eagle County Department of Human Services (ECDHS) recognizes the importance of supervised
visitation to maintain and improve the parent/child relationship when a child is placed outside of
the family home. Therapeutic supervised visitation is sometimes required when working towards
family reunification.
During therapeutic supervised visitation, a mental health professional supervises the visitation.
The mental health professional creates a safe, therapeutic environment, works directly with
parents to improve parenting skills and eliminate safety concerns during the visitation. The
mental health professionals have the authority to end the parent/child visit if safety concerns
arise.
The mental health professionals supervising therapeutic visits submit monthly reports
summarizing the service along with their invoices.
2. Indicate if a new Trails service detail is necessary for this County Designed Program or that the
service detail is already an option in Trails:
Service detail is already an option in Trails
3. Define the eligible population to be served:
The eligible population includes children and youth between the ages of 0-18 and their families
who have an open child welfare assessment or case.
4. Define the time frame of the service:
This service would be provided when a child is in out of home placement and the family is
working towards reunification but active safety concerns exist which require an extra layer of
therapeutic oversight during parent/child interactions.
10
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
5. Define the workload standard for the program:
Identify the number of cases per worker:
N/A, ECDHS employees would not provide therapeutic supervised visitation
Identify the number of workers for the program: N/A
Identify the number of workers to supervisor ratio: N/A
6. Define the staff qualifications for the service, e.g., minimum caseworker III or equivalent, see
7.303.17 for guidelines:
ECDHS contracts with mental health professionals who would provide the therapeutic supervised
visitation.
7. Define the performance indicators that will be achieved by the service, see 7.303.18:
Therapeutic supervised visitation works to reduce the length of stay in out of home placement
and supports the safety, permanency and well- being of children and youth. Identify the service
provider:
This is a direct service provided by various contracted service providers.
8. Define the rate of payment:
Contracted service providers: $90/hour for in office visits and $100/hour in home/off site/bilingual
services.
11
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31DEA7B8C7C4
CORE SERVICES COUNTY DESIGNED SERVICE
Service Name: Evidence Based Home Intervention
Optional services approved as a part of the County's Core Services Plan are approved on an annual
basis. For a County Designed Service to be extended beyond one year, this portion of the plan must be
submitted and approved annually by the State Department.
Given that County Designed programs are not standardized across counties, it is important to provide
detailed information as outlined below. The information listed below is to be completed for each
County Designed Service and included in the County's Core Services Program Plan.
1.Describe the service and components of the service; define the goals of the program:
Evidence Based Home Intervention is a voluntary evidence -based home visiting program serving
pregnant women and families of infants and young children. Evidence Based Home Intervention is
a prevention program dedicated to supporting families in their quest to be the best parents they
can be. Program services are designed to strengthen families during the critical first years of a
child's life. Services are focused primarily on prevention through education and support in the
homes of new parents.
2. Indicate if a new Trails service detail is necessary for this County Designed Program or that the
service detail is already an option in Trails:
Service detail is already an option in Trails
3. Define the eligible population to be served:
The child's age at Evidence Based Home Intervention enrollment is prenatal to age 24 months, up
to the child's 5th birthday.
4. Define the time frame of the service:
Intensity of services is based on each family's needs, beginning weekly and moving gradually to
quarterly home visits as families become more self-sufficient.
5. Define the workload standard for the program:
Identify the number of cases per worker:
N/A, ECDHS employees would not provide services through Early Childhood Partners.
Identify the number of workers for the program: N/A
Identify the number of workers to supervisor ratio: N/A
12
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
6. Define the staff qualifications for the service, e.g., minimum caseworker III or equivalent, see
7.303.17 for guidelines:
ECDHS contracts with community providers who implement the program in Eagle County.
7. Define the performance indicators that will be achieved by the service, see 7.303.18:
Therapeutic supervised visitation works to reduce the length of stay in out of home placement
and supports the safety, permanency and well- being of children and youth. Identify the service
provider:
This is a direct service provided by Early Childhood Partners through a county specific contract.
8. Define the rate of payment:
$100 per hour/in home/bilingual services.
13
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
CORE SERVICES COUNTY DESIGNED SERVICE
Service Name: Multi -Systemic Therapy (MST) and Multi-Systemtic Therapy - Contingency
Management (MST CM)
Optional services approved as a part of the County's Core Services Plan are approved on an annual
basis. For a County Designed Service to be extended beyond one year, this portion of the plan must be
submitted and approved annually by the State Department.
Given that County Designed programs are not standardized across counties, it is important to provide
detailed information as outlined below. The information listed below is to be completed for each
County Designed Service and included in the County's Core Services Program Plan.
This county designed service is intended to utilize funding for Evidence Based Services to
adolescents.
1. Describe the service and components of the service; define the goals of the program:
MST is an evidence -based, intensive, in -home treatment for youth who are at risk for out of home
placement. Treatment is designed to be short term, lasting 3-5 months with high frequency of
sessions: 2-3 times per week. Families have access to an MST therapist 24 hours per day through
a crisis phone.
MST -CM is an evidence -based, intensive, in -home treatment for youth who are at risk for out of
home placement and involved in delinquent behavior and substance use or substance abuse.
Families receive two (2) therapeutic visits per week and have access to the MST therapist 24 hours
per day through a crisis phone.
2. Indicate if a new Trails service detail is necessary for this County Designed Program or that the
service detail is already an option in Trails:
Service detail is already an option in Trails
3. Define the eligible population to be served:
Adolescents are eligible for this service.
4. Define the time frame of the service:
Treatment is designed to be short term, lasting 3-5 months with high frequency of sessions: 2-3
times per week. Families have access to an MST therapist 24 hours per day through a crisis
phone.
14
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
5. Define the workload standard for the program:
Identify the number of cases per worker:
N/A, ECDHS employees would not provide services through Health Families Vail Valley.
Identify the number of workers for the program: N/A
Identify the number of workers to supervisor ratio: N/A
6. Define the staff qualifications for the service, e.g., minimum caseworker III or equivalent, see
7.303.17 for guidelines:
ECDHS contracts with community providers who implement the program in Eagle County.
7. Define the performance indicators that will be achieved by the service, see 7.303.18:
Therapeutic supervised visitation works to reduce the length of stay in out of home placement
and supports the safety, permanency and well- being of children and youth. Identify the service
provider:
This is a direct service provided by Savio House through a county specific Core contract.
8. Define the rate of payment:
$2309 per month for two (2) visits per week
15
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7138C7C4
INFORMATION ON CORE SERVICE FEES
Please check all that apply:
X Fees will not be assessed for Core Services Program Services.
If the above line is checked, STOP. Remainder of information does not need to be completed.
El Fees will be assessed for the following services: Check those that apply:
❑ Home Based Intervention
❑ Intensive Family Therapy
❑ Life Skills
❑ Day Treatment
❑ Sexual Abuse Treatment
❑ County Designed Service (List Services Below)
❑ Special Economic Assistance
❑ Mental Health Services
❑ Substance Abuse Treatment Services
❑ Fee assessment formula is the same for all services. State the formula here (attach additional
sheets as needed).
LIFee assessment formula varies with service. State formula used for each service (attach additional
sheets as needed).
16
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
C�
G
O
m
W
N
P,
0
0
w
a
N
LLJ
U
OTC
LLJ
N
0
Z
in
Z
LL
O
N
0
00
N
N
O
N
W ,-.
W CA
00
U CA
LL
N
O
0000
O
'D
00
o
O
O
O
'0
V
M
N
v}
(/ }
�}
fV
N
O
V
V
L O
a
O
Ln
00
Lr)
O
Ul
CD
CD
4, 4J
UlLq
Lf1
Lq
O
O
O
o a
Ln
�O
Ln
00
Ul
O
CD
CD
V
Ul
ern
�
ern
a`
t/T
� L
L a L
V
Z�t N
N
v7
u"f
CD
M
N
"T
N
00
cn N
CUa�
4 +J
O c
cu O
li
N
O
O
O
�
N
N
V
on
an
a
a
o
Q—
00
0
0
00
00
00
u
Ln
O
M
Ln
Lun
O
O
O
O
O
L LU
V1
N
Vf
N
N
N
N
"a
"O
"a
"O
"a
'O
'O
O
0 �
a o
O
O
O
O
O
O
O
v �C
U
a
a
a
a
a
a
a
Ln
L C
L
V ai
OZ
O
O
O
O
O
O
O
1C:
i
i
i
L L
Wa
>
>
>
>
>
>
>
M
p
N
"0 C
N
O
u
fN0 C
N
O O
4-
Q O
O
N }, a
N m O
>
fC �
O N
InQ
c0
r..+
E�
0
N
O N
m(U
_Ea,
V
Y
�faC��,
a)
+-+ E
>,a>
4+
>,u aU
4-J
N
N L
+- .
Ln
L >
C
(� L N
L
�
iLX
°0 L..N L
o� a
O� p a;
_
NO
J
O
d�
V H �v1
V Htni
u W 2
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
O
O
M
OO
O
Ln
t/}
10
00
41
D
O
2
O
Ln
C
On u
� N
4
N
U�
00
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
� N
N
W O
a N
l7 W
0 > O
Z w N
=)I W
LL LA LL.
o ce
O
O U
N
L
Q
O
O
IT
O
1.0
�+
N
O
r,�
O
O
O
M
Lr)
O
Lf)
cV
cV
U
O
C
O
O
cp
00
L
U c
L O
° cG
° L
Lr)
00
000
v
rn
Ln a
O
00
.o
00
0
o
V
a`
M
r
Lrn
M
M
Ln
AA-
V-r
{/}
V'r
V'r
iJT
c a)
i a =
� -0 C
O O
V N
Ln
'T
fV
�O
OM
�O
to
N L
M O C
LL_ ::E
Oztt Ln N
Ln
o
o
v
Ln
(V
O
N !E
on
Q V
00
00
00
00
O
ao
O
O
O
O
U
Ln Q
O
L
W
N
Ln
W
O
N
O
M
0
L °
O
N
O
v° aU
-
W
H
a
o
a
i
° E
Li-
N
°
W
N
°
a_
Ln
°
O O
LnZ
N
O
O
i
�,
O
O
i
Nra
i t%
fV
i
>
C
!'
M
M
4�
N
a)
Ln
O N
0 E an
U O
Q '°
c
N
=
N
c
C
>
O2�
E
E
O
4J
v O NQ
W
N
O L
C
N
Ln
J
O (0 C v
V LL W::E
4-'
LL
a U H
Ln W Q
d
N
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
i
LU
aN0
t`oa
LLJLLI
� N U
Do—
OoN>
Q ILL Vf
Z LU
LL 0
u
Q 0
0 =)
LL
O
o
.o
o
O
0
0
0000
0000
0
C
7,.o
V:,
N
t/T
t/%r
t/T
t/}
t/T
a)
N u m
++
7 O O COLL
U_ _2 O
c6 00
O
O
O
78 N N aJ —
00
CD
CD2
O
0 C)
O
O
Lri
LU
ON
Q
y 0
N
O
O
�
O
O
O
00
O
10
0000
LL. 00
O
N
N
dd
V
on
c
o� L`�
ctj
Jou
�>v���
�
N O i
U r i
N N
O U +.+ ; U Ln
co i
a) Li U O
> 'O L
a) 00 C
E
_0
to N to C (o c '�
o"N:5Ln
> 'O L
N cn
u v> J
6
0-� O
; E
u L
a) '�,
ai r
to
an
a!1
i6 C a) E m
ant M
�Lum2
>u��
�LLIaLL. <u
LUCO
N Z Q
a1 O O
_0 4 Y U� C N
+�+� N�
a1 O U)
0
u3ooacbua
O
to
O
Q
C
v
N
(UE
N
N
VI
Z
aJ
c
>,
H
�
c E
a)
�
on
a,
a)
U-
�
aLn
`n
m
co
>
-0
Q v
Y
ro
a)
E
_
ro
aJ
( v
N
Ec
X
(U
=
roE
O
f
L
O
2
to V)
a
U H
O
Ln
��
��
"TOCV
::Ecv
f
11 7 0
N 00
(V 00
N 00
N 00
UL-U
X
X
X
X�
0
N
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
O
O
onon
O
M
N
ct�
ct�
O
O
N
Ln
N
O
O
M
O
00
Q
Q
Ln
N
M
ON
t/}
tR
th
VT
Z
Z
t/?
M
N
0O
Ln
N
O
06
Ln
fV
M
O
O
N
CD
M
Lb
41
>
>+
_U
OA
7 O
4'
on
Z
cd
O 4=
�, M
dd N
dd N
Cd N Q , c
N
N
O > O
a-J
O a)O
On
cd
O
O
On
5; O
c6
4-1
In > Lfa
�
fO
No
u
�van
tfC
ca
on t> C
a
LL-
ai
LuCOM:
�L2
UmumuLu<Lu
�L=ov)Li
c
O
L
U
N O
u3mQ
O
v
u
ate--,
VI
D
-0
LnLn
`n
Q
E
c
Q
v
2
v
u
O
a�
N
u
2
on
cn
o
4
c
o
on
v
on
on
N
'aU^.,
OU
Ln
m
O
O LU
O
LU
=
N
N
O
v
C
+�+ >' C
+�++
O
l6
l6
U
U
O },
O
7
N
_
(�
�Q
a,
O'
Ulli
O'
Ulli
O
O
N
L
�
Cv
O
-C .�
V)
Cv
v
�,
u LL L
U
i
V)
C
Cl:� C/1
U� V)
U
LL
00
Oq-
OLn
00
'IT Ln
'IT M-
N 00
N 00
N 00
X �
X
N
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
0
O
M
lJ}
LR
fV
.%O
fV
O
O
(V
�
N
V
L
O
CI4
O
07
0
06
(/}
5;
Q)
L
V V
L ;
N a)a)
N
Q
O
u o 3
qua)
L
C QJ
O
O
00 O
n N �
ltS
� � N
I—
O O �+
Ln
C O J
E
C
X X LL
on
f-, 000 p
N
`--
N N N
4� V
FL
V u u
N
V ::E
O O O
i+ Z; i+
u u u
N
C C C
J
Q
Li Li li
N N N
~
V V V
N
N
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
Ma
r
O
■
M
a
L
s
H
a
O
N
O
O
N
ti
O
O
N
I-
O
O
N
ti
N
E
L
CL
0
CD
O
0
cm
r-
cn
0
U
0
CD
CL
m
E
m
m
c�
m
H
Z
O
U
W
J
Q
W
M
N
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
0
,7
3
U-
c
a�
E
a)
0)
a3
C
cv
m
co
O
c6
O
U
xi
1
a)
cn
U-
U)
CO
d
cn
U-
cn
O
I—
U)
U)
Q
U)
Izt
N
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
C
0
Of
C
C
U-
m
V
d
co
L
O
V
L
O
U-
0
W
cn
Q
2
U
a
0
w
f�
0
w
a
W
in
0
U
O
U
CD
_O Q C
cu CD
� E
NN
_0 m U)
a)O O
U
m a
00 >
N C
O N
_ fn
x� x� x�
U)
CD
U
N
U)
N
U
C
N
C
U
Q
E
U
co
m
Vj
W
=
C
H
(J)
V
�
O
C
�
_O
0
J
w
(n
xl
xi
xil
x�
C21-279
O
C
O
O
U cu
-0 cn
�
E =_
O E
C fB
U-
E
�— _
N
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
ca
cG
G
w
_U
w
N
G
w
0
>
0
w
a
J
H
ci
w
r
Z
D
0
L)
N
N
O
N
T
N
O
N
LL
U)
N
Q
0
U�
U�
0
C
a�
o
U0-
0 0
7 t o
Z U U)
o
E E Z
ZLLU)
C
�aC:
t
a>U�
Q O U
O
c L
O�
n E w
� H
^O
LL Z LL
N
E
N
f0
U
0
0
z
N
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
U)
:i
.2:
C
y+
C
d
d
C
C
ca
C
O
C
N
L
IL
M
IL,
d
d
L
d
L
E
O
L
a-
W
a
H
W
D
m
J
Z
M
N
N
O
N
T—
N
O
N
U-
M
N
O
H Z
cl
M
M
M
M
OCI)LL
63
6,
6'
6q
61)
Q
63
U
� O
7
O
O
LL
O
O
O
H U
«
63
�O
'0 N
O
LL 00
N
CV
CV
CV
CO
N
M
M
M
M
M
M
CO
m
M
M
t0
0
HU
6q
�
> c
mE
-a)E
O
LL U 0 N
O
O
O
O
co 7— C
mnU�d
O
O
O
N
�c
6`k
�
�
�
C !E .2
�Um
C �
7 �
LL 0 f0
M 7
M
>a)
CU)>
Cli
LO
6,
L
�
L
L
L
L
L
a) a)
U -0
7-0
(0 a)
770
v) a)
770
a) a)
7-0
a) a)
7-0
a) a)
7-0
.>
a) OL
fL6 OL
m OL
ca OL
(0 2
(L6 L
N 2
U) I
i CD-i
O-
O-
O-
i O
O_
N c
�
C
a)
E
a)
U
E
7
ac
) c
70
o
E
co
m
.L+
H a)
LU N
d
E
U
U)
�
a)
a)
Z
a)
a)
(D
m U
m E
U
L
70 'o
70 2
to
U
C !A
U
rn
—
:2
a3
+T' E
� E
a)
.-
._
a)
U)
a)
O
U
O a)
U m
a) a)
U) U)
7 (D
U) cn
O
t`
N
C21-279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7B8C7C4
PURCHASE OF SERVICE CONTRACT
Core Services Program
THIS CONTRACT, made this day of , 21_by and between the County Department of
Human/Social Services at , hereinafter called "County" and (address) , (name) ,
(address) , hereinafter called "Contractor". (Tax I.D. or Social Security Number)
2. This contract will be effective from until
3. County agrees to purchase and Contractor agrees to provide (Core Service)
To at at other such (population to be served) (location service is to be provided)
location as shall facilitate the provision of such services. This service is described in Rule Manual Volume
7, Section 7.303.1 , and, if appropriate, the State approved County Core Service Plan.
4. County agrees to purchase and contractor agrees to furnish units of service at the cost of
per unit of service for a maximum amount of this contract of $
5. The parties agree that the Contractor's relationship to the county is that of an independent Contractor.
6. The parties agree that payment pursuant to this Contract is subject to and contingent upon the
continuing availability of funds for the purpose thereof.
County agrees:
a) To determine child eligibility and as appropriate, to provide information regarding rights to fair
hearings.
b) To provide Contractor with written prior authorization on a child or family basis for services to be
purchased.
c) To provide Contractor with referral information including name and address of family, social,
medical, and educational information as appropriate to the referral.
d) To monitor the provision of contracted service.
e) To pay Contractor after receipt of billing statements for services rendered satisfactorily and in
accordance with this Contract.
Contractor agrees:
a) Not to assign any provision of this Contract to a subcontractor.
b) Not to charge clients any fees related to services provided under this contract.
c) To hold the necessary license(s) which permits the performance of the service to be purchased,
and/or to meet applicable Colorado Department of Human Services qualification requirements.
d) To comply with the requirements of the Civil Rights Act of 1964 and Section 504, Rehabilitation Act of
1973 concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
e) To provide the service described herein at cost not greater than that charged to other persons in the
same community.
f) To submit a billing statement in a timely manner, no later than forty-five (45) days after services.
failure to do so may result in nonpayment.
g) To safe guard information and confidentiality of the child and the child's family in accordance with
rules of the Colorado Department of Human Services and the County Department of Human/Social
Services.
h) To provide County with reports on the provision of services as follows:
• Within weeks of enrollment/participation, submission of a treatment plan for the
child/child's family with specific objectives and target dates. The treatment plan is subject
to county approval.
• At intervals of months, from the time of enrollment/participation, submit reports that
include progress and barriers in achieving provisions of the treatment plan.
C21279
DocuSign Envelope ID: DE6522A0-2F98-4EA7-AFA5-31 DEA7138C7C4
i) To provide access for any duly authorized representative of the County or the Colorado Department
of Human Services until the expiration of five (5) years after the final payment under this Contract,
involving transactions related to this Contract.
j) Indemnify the County and the Colorado Department of Human Services from the action 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
violation of any statue, regulation, and the defense of any such claims or actions.
9. In addition to the foregoing, the County and Contractor also agree:
10. Termination: Either party may terminate this Contract by thirty (30) days prior notification in writing.
11. All payments will be paid through the State's approved automated system, as appropriate.
Core Services Program expenditures will not be reimbursed when the expenditures may be reimbursed by
some other source. (As set forth in Rule Manual Volume 7, at 7.414, B (12 CCR 2509-5).
ADDITIONAL PROVISIONS:
County Director's Signature Contractor's Signature
Date Contractor's Title
Original to Contractor
Copy to the Case File
Copy to County Bookkeeping
Copy to State Accounting
Date
C21-479