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HomeMy WebLinkAbout2017-639-E Finance - KidSCope Chapel Hill Training Outreach Project, Inc. - Outside Agency Performance Agreement DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2017, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and KidSCope: Chapel Hill Training Outreach Project, Inc., a not-for-profit corporation, located at 800 Eastowne Dr., Suite 105, Chapel Hill, NC 27514 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and KidSCope: Chapel Hill Training Outreach Project,Inc. agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30,2018. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 75000 b. All funds appropriated shall be used for purposes described in Exhibit B. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of 18750. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. (KidSCope: Chapel Hill Training Outreach Project,Inc.) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 - June 30. Reports are due on January 12,April 13, and July 13 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services,upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default"), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider,the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten(10)business days from written notice of default. The County may (but shall not be required to) grant the (KidSCope: Chapel Hill Training Outreach Project,Inc.) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers'or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury,including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A- Statutory State NC & Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability) required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 (KidSCope: Chapel Hill Training Outreach Project,Inc.) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves,their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.75 per hour. To the extent possible, Orange County recommends that KidSCope: Chapel Hill Training Outreach Project, Inc. provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices (KidSCope: Chapel Hill Training Outreach Project,Inc.) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: County: Finance &Administrative Services Provider: KidSCope: Chapel Hill Training Orange County Outreach Project,Inc. Post Office Box 8181 800 Eastowne Dr., Suite 105 Hillsborough,NC 27278 Chapel Hill,NC 27514 16. Entire Agreement. This Agreement,including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. 18. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 19. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and on behalf of the Provider (KidSCope: Chapel Hill Training Outreach Project,Inc.) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 FiDocuSigned by: at, ('t4d.%S 11/27/2017 -9e D Ae-, go... , Date Focaddo �1,alf of Orange County Government NIAAut, l'a.wtwtt,V'S�,t 11/27/2017 O637994D75 E477... Bonnie Hammersley, County Manager Date (KidSCope: Chapel Hill Training Outreach Project,Inc.) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FY 2017-2018 Outside Agency Funding Application HUMAN SERVICES • ORANGE COUNTY • TOWN OF CARRBORO • TOWN OF CHAPEL HILL Orange County (OC) Town of Carrboro (CA) Town of Chapel Hill (CH) 200 S. Cameron Street 301 W. Main Street 405 Martin Luther King, Jr. Blvd. Hillsborough, NC 27278 Carrboro, NC 27510 Chapel Hill, NC 27514 aR 4'6 FCAR 0hh S;f OA* „ j/ �� DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency Chapel Hill Training Outreach Project Received By Program(s) KidSCope Date/Time Section Subsection 1. Cover Page a. ❑ Applicant Contact Information b. ❑ Funding Requests c. ❑ Signed Application Cover Page d. ❑Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. ❑ Agency's Years in operation b. ❑ Agency's Purpose/Mission c. ❑ Agency's Types of Services Provided d. ❑ Agency's Experience with Programs e. ❑ Other Pertinent Agency Information f. ❑ Schedule of Positions g. ❑ Living Wage h. ❑ Agency Budget 3. Program Information a. 111 Human Services Needs Priority b. ❑ Type of Program A separate Section 3 is c. ❑ Agency Collaboration required for each program. d. ❑ Summary of Program e. [' Description of Identified Need f. ® Description of Population to be Served g. ❑ Program Staffing, Capacity, & Expertise h. ❑ Program Implementation Timeline i. ❑ Value of Investment j. ❑ Impact of Reduced/No Allocation k. ❑ Other Pertinent Information I. ❑ Target Population/Beneficiary Chart m. ❑ Work Statement n. ❑ Program Budget, Detail, &Cost per Individual 4. Attachments a. ❑ Audit: Organizations receiving $300,000 or more in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ❑ NC Solicitation License d. ❑ IRS Federal Tax-Exemption Letter e. ❑ Certificate of Insurance f. ❑ List of Board of Directors g. ❑ Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 2/9/2017 11:59:17 AM u DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION I. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: KidSCope/Chapel Hill Training Outreach Project, Inc. Applicant Organization's Physical Address:800 Eastowne Drive, Ste.105,Chapel Hill, NC 27514 Applicant Organization's Mailing Address: 800 Eastowne Drive, Ste. 105,Chapel Hill, NC 27514 Applicant Organization's Web Address: chtop.orq Executive Director: Mike Mathers Telephone Number: 919-490-5577 x 223 E-Mail: mmathers ( chtop.orq Tax ID Number: b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total - HS Hill- HS Count -HS Ex, Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for outh activities and projects 1 KidSCope Outreach: Early Childhood Mental Health $2,000.00 $4,500.00 1 $75,000.00 $81,000.00 therapist salary and_program expenses KidSCope Children's Learning Center: 1 $49.000 $49,000.00 Moving and program expenses to relocate Children's Learning Center to new Hillsborough site at Orange Enterprises 1 1 1 1 1 _ 1 1 I Totals $2,000.00 $4,500.00 $124,000 $130,000.00 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: , Executive Director Date (L- , „ 1 i , ', Signature: / ,, ti.k,N(1._ L.,/ L ,A I, itil 6'ir,R 01 1 Ballard Chairperson f Da e DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? 1— i4 b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? LI i4 c) Current beneficiaries of the program for which funds are being requested? d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: ?,),// // /7 ( Executive Di or Date (IC Signature: (-2/(a4 '(a,, 6,(2? Bdard Chairperson Dat DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): 4/6/88 KidSCope was created in 1988 under OPC Mental Health Center. b) Agency's Purpose/Mission (no more than a few sentences): • The mission of KidSCope is to provide comprehensive early childhood developmental/mental health support to young children, their families, and care providers. Through the use of research and specialized evidence based services, KidSCope aims to give children a healthy start in the early years, when relationships and experiences influence future life success the most. c) Types of Services the Agency Provides (bullet format): KidSCope provides: • inclusive early childhood education • social-emotional health services using evidence-based modalities, including Parent Child Interactive Therapy and Child Parent Psychotherapy, • child care mental health consultation and teacher education • parent education-Incredible Years Basic/Incredible Babies/Toddlers. • a myriad of childhood development and parenting resources d) Agency's History with Providing These Services: KidSCope was created in 1988 under OPC Mental Health Center, by a coalition of professionals and child advocates, to address a documented need for specialized services to young children who are experiencing social, emotional, and/or behavioral difficulties. KidSCope was divested under state mental health reform to a local non- profit, Chapel Hill Training Outreach Project, Inc. on October 1, 2005. The Children's Learning Center started in 1973 under OPC Mental Health Center to provide a community option the education of children with special needs, joining the KidSCope Outreach program in 1999. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director?Are there new initiatives?) In the fall of 2016, KidSCope was notified that our lease with Orange County Schools would be ending on June 30, 2017. We have found a new location on the campus of Orange Enterprises in Hillsborough. We plan to build or lease a modular building to relocate the staff and children. We are requesting funds in the amount of $49,000 to move our program. f) Schedule of Positions (For Entire Agency) # of FTE - Full-Time Paid Positions: 12 # of FTE - Paid Part-Time Positions: 23 # of Volunteers: 10 # of FTE -Volunteers:.05 g) Living Wage Agency Information i �i , enc 7 5 � 7 ° �:: �; DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Does this agency pay permanent employees a minimum living wage? (Yes /No) No If yes, is this agency an Orange County Living Wage Certified Employer? If no, please explain. Paying our employees a "living wage" is a goal for the KidSCope program that we are very close to achieving. KidSCope is, however, a program of Chapel Hill Training Outreach Project, Inc., a non-profit with many employees. Although the goal of paying a minimum living wage is an admirable one, KidSCope is not involved in salary decisions for the entire organization. h) Agency Budget Is your agency currently receiving and/or requesting other (non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) No If yes, please list below: Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY16- FY17-18 Source 17 Request Award Ex: Affordable Rental 0 $20,000 Carrboro - Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $15,000 Carrboro — Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. Agency : : �� ,� II 1 enc Information 2/9/2017 5 � 7 P �:� 1 DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION i. Submit your agency's budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOME/etc.) • Private Foundation Grants o Other Revenue • Expenditures o Compensation o Rent & Utilities o Supplies & Equipment o Travel & Training o Other Expenses ii. Does your agency budget show a Surplus or Deficit? Deficit Is there a significant change? Yes/No Yes Please provide a brief explanation for Surplus or Deficit, and significant changes. Agency Information 2/9/2017 11:59:17 AM 8o 8 o If I "'i"" DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION For the Children's Learning Center Budget: FY 16-17: KidSCope operates three (3) Developmental Day Centers. In total these centers are projected in total to have a $12,451 surplus, primarily due to the program in Siler City. FY 17-18: The (3) KidSCope Developmental Day Centers are projected in total to have a $15,912 deficit. The deficit is primarily due to moving costs of the CLC childcare totaling $49,000. For KidSCope Outreach Decreases in Medicaid reimbursement rates still represent an annual loss of funding, and threaten our ability to serve all of the children referred. Medicaid funding is a large part of our revenue. Although we are successful at accessing Medicaid funds, the entire mental health system is remains underfunded and fragile. The volatility of the federal, state, and local economic picture continues to threaten our funding as well. The uncertainly of the future of the mental health system under DHHS, including the possibility of outsourcing mental health/Medicaid to the private sector, has everything on hold. Until this crucial decision is resolved, issues regarding rate increases and development and implementation of new services will remain unstable. -- What is your agency's fiscal year? July 1, 2017-June 30, 2018 Agency Information 2/9/2017 11:59:17 AM :: ;I t o If I "' DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: KidSCope Outreach Program Primary Contact and Title: Linda Foxworth, Director Telephone Number:919-644-6590 x 4810 E-Mail: Ioxworth@kidscope.chtop.org a) Indicate the type of Human Service Needs Priority, if program applicable: ® Priority Area #1: safety-net services for disadvantaged residents ® Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ® Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare x Education x Family Resources x Jobs/Jobs Training Food Transportation Other: Please specify c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. KidSCope coordinates services with the similar programs and agencies in order to ensure that children in need are identified and referred in a timely, efficient manner. These agencies include: • Children's Developmental Services Agency (CDSA) • Orange County Department of Social Services • Child Care Services Association • Orange County Health Department PROGRAM INFORMATION 2/9/2017 11:59:17 AM I: W,1 gc 10 u0 f I / DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Family Success Alliance • Orange County Partnership for Young Children • Orange County Schools • Chapel Hill/Carrboro City Schools • Head Start/Early Head Start • Cardinal Innovations Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? KidSCope proposes the following services: • Customized assessment and evaluation for children ages birth to 5, and their families, to determine strengths and needs, • Social-emotional/behavioral health services using researched, evidence-based treatment modalities providing both home visiting and office based options. These programs are designed to give children a healthy start in the early years when relationships and experiences influence brain development the most. • Parent education that encourages and supports positive family relationships and interactions, particularly in the early years. These programs include the Incredible Years Basic/Incredible Babies/Toddlers. By proposing these services- • KidSCope addresses Orange County Goal 1, Priority Four, Protect Safety Net Programs • KidSCope addresses all three priority areas for the Town of Chapel Hill • KidSCope addresses the Town of Carrboro's Goal of Improving Services for Citizens e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro goals, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. The number of children in poverty has increased in Orange County since 2009 from 9.4% to 16.8% in 2011. This number has increased even more since then, with high PROGRAM INFORMATION 2/9/2017 11:59:17 AM Page 11 , If 1 "'°"' DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION poverty areas in the County of up to 22%. In early childhood, research on the biology of stress indicates that major adversity, such as extreme poverty, above, or neglect can affect brain development and permanently set the child's stress level on high alert. Chronic stress can be toxic to the brains of young children. The Chapel Hill Human Needs Assessment identified Affordable Healthcare and Education and Family Resources as key human needs and priorities for funding. Orange County Goals Goal 1: Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents. Goal 6 Ensure a high quality of life and lifelong learning that champions diversity, education at all levels, libraries, parks, recreation, and animal welfare • KidSCope is a collaborative partner with FAMILY SUCCESS ALLIANCE. • KidSCope provides access to developmental and mental health screening and services, and parent education resources to increase positive parenting skills. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? KidSCope provides mental health and family support to children birth to 5 and their families in Orange County. KidSCope services prepare families for positive early experiences that "scaffold" healthy development, and build a foundation for later skills and learning capacities. Families may self-refer, or referrals may be made by other agencies such as Cardinal Innovations, Orange County Department of Social Services, Orange County Health Department, local child care programs, Head Start and Early Head Start, School Systems, medical facilities, the court system, or a variety of other sources. Ultimately, families/guardians make the decision to receive services. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Linda Foxworth is the founder of the KidSCope program and has been its director since 1988. Linda has more than 40 years of experience working with young children with special needs and their families. She has served on numerous local and state- wide committees and task forces. As Director of KidSCope in Orange and Chatham Counties, Linda has been responsible for administration of programs that provide mental health and developmental disabilities services for young children and families. Linda has a BA in Sociology and Master's Degree in Special Education, specializing in Early Childhood Handicapping Conditions. Kathy Eden is the KidSCope Outreach Clinical Coordinator and is a Licensed Clinical Social Worker whose specialty is children and families. Kathy has a family- PROGRAM INFORMATION 2/9/2017 11:59:17 AM I ' : , 12 00 I / DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION focused approach with the goal of strengthening parent skills and knowledge to help children meet their developmental potential. She also specializes in working with children with autism and their families and has worked for KidSCope since 2007. KidSCope Outreach volunteers participate as members of the KidSCope Advisory Council. They are not directly involved in providing services to families. Volunteers are trained in all program functions and activities annually. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Timeline Task/Activity Responsible Party July, 2017-August 1,2017 Develop new program public Therapists and intake awareness information staff July 1, 2017-June Distribute flyers/referral info to Therapists, intake and 30,2018 community partners other KidSCope staff July 1, 2017-June Accept referrals to program Therapists 30,2018 July 1, 2017-June Administer Pre-tests to Therapists 30,2018 participants July 1, 2017-June Provide services to Therapists 30,2018 children/families July 1, 2017-June Provide Post-tests to families Therapists 30,2017 when they complete services or every 6 months July 15, 2018-September Administer surveys to participants Therapists and 30, 2018 as they leave services, or at the administrative staff end of the fiscal year. Analyze data to present to Advisory Council and complete reports i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) KidSCope interventions with speak to families "where they are" because they focus on the development of healthy families relationships. KidSCope provides access to health care services for those who have Medicaid, private insurance or are uninsured. The groundbreaking studies of economist/ Professor James Heckman show that "high quality birth-to-five programs for disadvantaged children can deliver a 13% per child, per year return on investment through better outcomes in education, health, social PROGRAM INFORMATION 2/9/2017 11:59:17 AM I:) ;i g u a If I "'°"' DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION behaviors and employment, reducing taxpayer costs down the line and preparing the country's workforce for a competitive future". j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Although we would continue to seek funding from other sources, if funding is not received through this application for the KidSCope Community Outreach program, the program will not be viable, or available to Orange County children and families. k) Include any other pertinent information. None noted. PROGRAM INFORMATION 2/9/2017 11:59:17 AM P c „1 o If "1 "7' DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information a) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 38 55 60 Female 19 35 40 Total 57 90 100 Ethnicity African-American 17 30 35 American Indian or Alaska Native 0 0 0 Asian 0 0 3 Caucasian 33 40 37 Native Hawaiian or other Pacific Islander 0 0 0 Other: specify Hispanic,Bi-racial. Arab 7 20 25 Total 57 90 100 Of the above, how many Hispanic/Latino 3 20 25 Of the above, how many non-Hispanic/Latino 54 70 75 Total 57 90 100 Age 0-5 years 57 90 100 6-18 years 19-50 years 51+ years Total 0 0 0 Geographic Location Alamance County 2 0 Chatham County 3 4 Durham County 0 0 Wake County 0 0 Orange County Breakdown Chapel Hill Public Housing 0 0 5 Town of Chapel Hill (Non-Public Housing) 17 30 30 Town of Carrboro 2 10 11 Town of Hillsborough 15 20 20 City of Mebane (Orange County) 13 15 15 Orange County (Outside Municipalities) 5 15 19 Total 57 90 100 PROGRAM INFORMATION 2/9/2017 11:59:17 AM Page 15 7' DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement b) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time- bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program: KidSCope Outreach 1. Program Activity Name Assess children 0-5 to determine needs Program Goal Assess 122 children in Orange County Performance Measures 91 children will be assessed Previous Year Program Results 57 children were assessed Current Year Estimated Results 90 children will be assessed Next Year Projected Results 100 children will be assessed 2. Program Activity Name Provide Evidence Based therapeutic interventions to improve behaviors Program Goal Provide to 100 children and family members Performance Measures Provide to 91 children and families Previous Year Program Results Provided to 57 children and families Current Year Estimated Results Provide to 90 children Next Year Projected Results Provide to 100 children children 3. Program Activity Name Provide Individual counseling and education to families to increase knowledge of successful parenting Program Goal Provide to 100 children and the family members Performance Measures Provide to 90 children and their family members Previous Year Program Results Provided to 57 children and their family members Current Year Estimated Results Provide to 90 and their family members Next Year Projected Results Provide to 100 children and their family members 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PROGRAM INFORMATION 2/9/2017 11:59:17 AM 0 ' ago °16 00 °"1 / DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget 1. Submit your program budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues O Private Donations O Program Generated Revenue O Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other(DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) O Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOME/etc.) • Private Foundation Grants O Other Revenue • Expenditures O Compensation O Rent & Utilities O Supplies & Equipment O Travel & Training O Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. None noted. 3. This program budget represents what percent of the agency budget 7% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Includes children AND family members Actual 2015-1.6 Estimated 2016-17 Projected 2017-18 Total Cost of Program $166,871 $162,375 $162,375 Total # of Individuals 143 225 250 Cost Per Individual $1,167,00 $721.00 $649.50 PROGRAM INFORMATION 2/9/2017 11:59:17 AM 0'' u q e 00 I "'" DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Chapel Hill Training-Outreach Project, Inc. (KidSCope) Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 66,736 $ 14,600 $ 19,600 34% Agency Generated Revenue (fees) $ 790,875 $ 1,033,358 $ 1,050,711 2% Local Government Grants: Orange County $ 75,000 $ 75,000 $ 75,000 0% Town of Chapel Hill $ 4,500 $ 4,500 $ 4,500 0% Town of Carrboro $ 2,200 $ 2,200 $ 2,200 0% Chatham County $ 3,000 Other Local: Strowd Roses $ 5,000 0 Other Local: Misc $ 4,357 0 Other Local: 0 provide a separate list. Non-Local Government Grants Triangle United Way $ 56,251 $ 58,068 $ 58,068 0% State Government 0 Federal Government $ 322,549 $ 374,296 $ 374,296 0% Other Grants: NC Pre-K $ 148,630 $ 214,500 $ 214,500 0% Other Grants: CACFP $ 56,061 $ 65,561 $ 65,000 -1% Miscellaneous/Other Revenue $ 347,744 $ 327,991 $ 332,991 2% Please list 3 largest Miscellaneous sources 17-18: Total Agency Revenue $ 1,882,902 $ 2,170,074 $ 2,196,866 1% AGENCY EXPENSES Compensation $ 1,498,058 $ 1,609,054 $ 1,611,389 0% Rent& Utilities $ 93,678 $ 95,215 $ 129,359 36% Supplies&Equipment $ 97,680 $ 65,088 $ 65,465 1% Travel &Training $ 39,844 $ 38,214 $ 38,458 1% Other Expenses: $ 358,465 $ 390,627 $ 408,682 5% Please list 3 largest"Other Expenses" 17-18: Indirect Cost to CHTOP, Inc $ 133,116.00 Contracted Services $ 116,180.00 Rent& Utilities $ 108,135.00 Total Agency Expenses 2,087,726 2,198,198 2,253,353 3% SURPLUS/(DEFICIT) FOR PERIOD: ($204,823)1 ( ,124) ($56,487)1 -101% DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 EXHIBIT `B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Chapel Hill Training Outreach Project Program Name: KidSCope Funding Award: $75,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Salary and benefits for staff to implement the program $75,000 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Assess/evaluate children who are referred to the KidSCope Program to determine needs • Provide therapy or other individual/family interventions to support positive primary relationships for children and to improve behavior and social skills. • Provide parent education to families to increase knowledge of successful parenting. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results By June 30,2018, 100 children of 122 referred will receive evidence based assessment 91/122 By June 30, 2018, 75% of children served by KidSCope Outreach will show 75/100 improvement in behavior and social skills By June 30, 2018, 95% of families surveyed will report improvement in their child's 95%of ability to get along better with children and adults those surveyed By June 30, 2015, 97% of parents surveyed will report learning new parenting stratgies 97%of and understanding of child development. those surveyed DocuSigned by: Nl.lkt, kA $ Executive Di rector 11/27/2017 `—9B7DAAC75A85490... Certified by: ..&ida 9axwanea Title: KidSCope Director Date: 7/21/17 (Provider's Signature) DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 ATTACHMENT "A" Orange County Certifications—FY 2017-18 Outside Agency Performance Agreement Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name,title,residential address;phone and email address and if possible,fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DocuSigned by: hilt, hall""y� ' ' Executive Di rector 11/27/2017 Certified by: 9g7DAAC75A85490... Title: Date: (Provider's Signature) (KidSCope: Chapel Hill Training Outreach Project,Inc.) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 onnunign Envelope ID:nosEFCno-D47o-4nsa-8Ano*Aorennnc000 20CHAPEH|L3 A C O D" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) u2/O2/2O17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.T*m 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:| 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 CONTACT BB&T Insurance Services Inc. Beth ��—� ' ' 19 2 U�� w� 888 746-8761 P�1O��Bon13�1 �=~' ' �G��o . uow||xors�nK�bbmndLcnm Durham, NC 27709 ~ --- ---- --- 919 281-4500 w'vnER(S)^rronDING COVERAGE wwcv 18058 INSURED Accident Fun�|nsCoo��merica 10166 Chapel HiUTraining Outreach Pn� Inc �---- --- �---- --- �----- 800Eas*ovvneDr Ste 1U5 ` ---- �---- ---� �----- -----� Chapel HiN. NC 27514 /'`` D'-- --- ---- ----�� ��----- ---- INSURER E/_� ��_-__' _---� ---- --- ------ INSURER,. 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' . . CERTIFICATE HOLDER ' CANCELLATION Orange County Human Services SHOULD ANY or THE ABOVE DESCRIBED POLICIES as CANCELLED BEFORE THE EXPIRATION DATE r*snsop, NOTICE WILL BE DELIVERED IN Attn:Allen Coleman, PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE »�~�~ � � I � vv�� 7��- — k^ ©1xo14 ACORD CORPORATION,All rights reserved. ACORD 25(2014/01) 1 of The ACORD name and logo are registered marks of ACORD #S17581687/M17581383 BG3