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Home My WebLink About20132765.tiffMEMORANDUM DATE: August 22, 2013 TO: William F. Garcia, Chair, Board of cou got r FROM: Judy A. Griego, Director, H RE: issioners ki--0D lrtme t Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility between the Weld County Department of Human Services and Various Providers for Consent Agenda Enclosed for Board approval is an Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement between the Department and Various Providers. These were reviewed under the Board's Pass -Around Memorandum dated July 17, 2013, and approved for placement on the Board's Agenda. The major provisions for these Agreements are as follows: No. Provider/Term Facility Type/Location Daily Rate 1 Almond, Earl and Cindy July 1, 2013 — June 30, 2014 Foster Home Johnstown, Colorado $16.32 - $40.11 2 Arnett, Casey and Lindsay July 1, 2013 — June 30, 2014 Foster Home Loveland, Colorado $16.32 - $40.11 3 Carter, Jeremy and Susan July 1, 2013 — June 30, 2014 Foster Home Milliken, Colorado $16.32 - $40.11 4 Drury, Dean and Karla July 1, 2013 — June 30, 2014 Foster Home Greeley, Colorado $16.32 - $40.11 5 Erbacher, Dan and Hallie July 1, 2013 — June 30, 2014 Foster Home Greeley, Colorado $16.32 - $40.11 6 Fritz, Nancy July 1, 2013 — June 30, 2014 Foster Home Evans, Colorado $16.32 - $40.11 7 Froggate, Samuel and Rachelle July 1, 2013 — June 30, 2014 Foster Home Greeley, Colorado $16.32 - $40.11 8 Gomez, Oswald and Christina July 1, 2013 — June 30, 2014 Foster Home Fort Collins, Colorado $16.32 - $40.11 9 Hanke, Mark and Kerri July 1, 2013 — June 30, 2014 Foster Home Salem, Oregon $27.06 10 Heard, John and Kimberly July 1, 2013 — June 30, 2014 Foster Home Mead, Colorado $0 11 Jacobsen, Tara and John July 23, 2013 — June 30, 2014 Foster Home Westminster, Colorado $16.32 - $40.11 2013-2765 C - 30-I3 12 Kirchoefer, John and Erin July 1, 2013 — June 30, 2014 Foster Home Fort Collins, Colorado $16.32 - $40.11 13 Kniss, Kevin and Kelly July 1, 2013 — June 30, 2014 Foster Home Thornton, Colorado $16.32 - $40.11 14 Maronek, Dennis and Patricia July 1, 2013 — June 30, 2014 Foster Home Firestone, Colorado $16.32 - $40.11 15 McCreery, James and Tammy July 1, 2013 — June 30, 2014 Foster Home Eaton, Colorado $16.32 - $40.11 16 McNear, Nikki July 1, 2013 — June 30, 2014 Foster Home Loveland, Colorado $17.00 17 Mena, David and Marie July 1, 2013 — June 30, 2014 Foster Home Greeley, Colorado $16.32 - $40.11 18 Pierce, Larry and Kris July 1, 2013 — June 30, 2014 Foster Home Greeley, Colorado $16.32 - $40.11 19 Roderick, Douglas and Kelli July 1, 2013 — June 30, 2014 Foster Home Greeley, Colorado $16.32 - $40.11 20 Serna, Leo and Carol July 1, 2013 — June 30, 2014 Foster Home Windsor, Colorado $16.32 - $40.11 21 Sims, Mildred July 1, 2013 — June 30, 2014 Foster Home Dayton, Ohio $27.18 22 Terry, Royce and Michael June 28, 2013 — June 30, 2014 Foster Home Enid, Oklahoma $13.45 23 Van Den Elzen, Dawn July 1, 2013 — June 30, 2014 Foster Home Greeley, Colorado $16.32 - $40.11 24 Wade, Michael and Jodyne July 1, 2013 — June 30, 2014 Foster Home Windsor, Colorado $16.32 - $40.11 25 Willert, Melody D and Lee, Kimberly July 1,2013 — June 30, 2014 Foster Home LaSalle, Colorado $16.32 - $40.11 26 Wurtz, Drew and Workman-Wurtz, Katherine July 1, 2013 — June 30, 2014 Foster Home Greeley, Colorado $16.32 - $40.11 If you have questions, please give me a call at extension 6510. INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this day of , 20 IS , by and between the Board of County Commissioners of Weld County, on be alf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Almond, Earl and Cindy, whose address is 1000 Country Acres Dr., Johnstown, CO 80531, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. Any emergency. g. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A S -7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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 C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST• By: Deputy C k to the B Approval as to Substance: WELD COUNTY DEPARTME OF HUMAN SERVICES By: The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services Gym eiGu ademachex; Chairman Protein RACTOR: SEP 3 0 2013 mond, Earl and Cindy 1000 Country Acres Dr. Johnstown, CO 80531 By: 699/3 Director's (or designee's) Signature and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 at7%3- 716 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Almond, Earl and Cindy, hereinafter referred to as; "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 61603. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4`h of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The team "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A S -7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑ Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3%n) 7 round trips or more Comments: ❑ l) One round trip a week ❑1'%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? O Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more Comments: ❑ I) Once a month ❑1%) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O Basic Maint.) No educational requirements ❑2) 1 hour a day 03%) More that 3 hours per day Comments: ❑ 1) Less than a'/z hour per day 011/2) 1/2 hour a day 02 %) 1'/r2 hours per day 03) 2'/z-3 hours per day P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.) No special involvement needed 01) Less than 5 hours per week ❑1%:) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week O 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑ 1) 3 to 4 hours per week ❑1'/) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑I) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1/) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. O 2%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) DI) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month Exhibit "B" to the Additional Provisions 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions (cheek one box for each cats °{� orYl Assessment Areas Note Mild Mild/ Moderate 'Moderate/ 'Huh High/ Continents: Moderate. High 21/2 Severe 0 1 1 1/2 2 3 31/2 Aggression/Cruelty to Animals ❑ 0 ❑ ❑ ❑ ❑ • Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ■ ■ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious Behavior ❑ ❑ 0 ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ � ■ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ • Runaway ❑ ❑ ❑ 0 ❑ • ■ Sexual Offenses ❑ 1 ❑ ❑ ❑ ■ ■ ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 • EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. a? i O Rating of Conditions 4� �, , _ �,,:.ig .: i (Check one box for each category ) sts sr �� .t'ra }..,a; Ls 4L„': nk:li be �' , Assessment Areas None Mild Mild/ Moderate Moderate/ Mob Dieu Comments: Moderate. Ellen Severe 0 I 11/2 2 2 1/2 3 3 1/2 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ 0 0 ❑ Disruptive Behavior ❑ 0 ❑ ❑ ❑ ❑ • Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ • • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ ❑ Emancipation ❑ ❑•❑ ❑ ❑ ■ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ■ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ■ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ • ■ Involvement with Child's Family ❑ ❑ ❑ ❑ 0 ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 21/2 ❑ 3 l 31/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 • EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 4�T'_'fI >� � h��§b.� ��,• s�r+3 e§ ��`R�`i t4':Y`{�q��•�� ''_ §.v...�s:.,a+3'la1'%eEbkla- "k County Basic Maintenance Rate Age Age 0-10...$16.32/day 3 Age 11-14...$18.05/day ,a Age 15-21...$19.27/day y� a + Respite Care $.66/day 1 a $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 avE a»� $23.01 +$.66 Respite Care ($23.67 day) 2 $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 $29.59 +$.66 Respite Care ($30.25 day) 3 # dam $32.88 +$.66 Respite Care ($33.54day) 3 1/2 4-) i $36.16 +$,66 Respite Care ($36.82 day) 4 RCCF Drop Down X50 �`: $39.45 +$.66 Respite Care ($40.11 day) w.. .l Assessment/Emergency Rateiv@ ie $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this `b day of d,-tw_ , 20 by and between the Board of County Commissioners of Weld County, on behlf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Arnett, Casey and Lindsay, whose address is 1545 Chickadee St., Loveland, CO 80537, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WFINESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 O7th - 07,65 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange throughstatewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: The Board of County Commissioners of Weld County, on behalf of the Weld County Department ATTEST`\e`"' of Human Services B Deputy !Perk to the Boa Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: ademacher, Chairman Protein CTOR: ett, Casey and Lindsay 1545 Chickadee St. Loveland, CO 80537 SEP 3 0 2013 By: Director's (or designee's) Signature and Date / !' _ mod; /2 CWS-7A Individual Provider Contract 9 Revised 6/2013 o?a/.3-,?XS EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Arnett, Casey and Lindsay, hereinafter referred to as, "Contractor." GENERAL PROVISIONS County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1614609. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4`h of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shalt require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor; or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The teini "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A S -7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? 1 El Basic Maint.) Less than one round trip a week ❑1) One round trip a week 01%) 2 round trips a week ❑2) 3-4 round trips a week. ❑2'/z) 5 round trips a week 03) 6 round trips a week 03%) 7 round trips or more Comments: P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required ©1) Once a month 01%) Two times month 02) Three times a month 02%) Once a week 03) Two times a week 03%) Three times a week or more Comments: `;‘—'ak Swyc \ - \ ,V cL w vVwb v�t�� ^ P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular u;pv,,# or special education plan? u Basic Maint.) No educational requirements ❑2) 1 hour a day ❑3'/z) More that 3 hours per day Comments: ❑1) Less than a'' /z hour per day Ell 'A)'/z hour a day 02 1/2) 1'/z-2 hours per day ❑3) 2'/z-3 hours per day P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week ❑1'/z) 5 to 7 hours per week ❑7) 8 to 10 hours per week ❑VA) 11 to 14 hours per week 3) Constant basis during awake hours 3%z) Nighttime hours Comments: \ra S� c \Ca,v� P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week 0;) 8 to 10 hours per week Luj3%) 21 or more \^� hours 1�' per week Comments: M `L t ` ❑1) 3 to 4 hours per week 011/2) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ l) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. O 2) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. . **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month Exhibit "B" to the Additional Provisions 5 ❑1) Less than 4 hours per month 03) 9-12 hours per month Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. L_, £ r i : :,x, l a iH Ilia r..:. £ x t `i . ii t.. ,t£' �� w.:£ r`, •£ »s i>, ., :«a 9 : ..,rihr. ,, .. - •� ,': f,'� ;x��•_ ,fir, �{4y s ;' ..,. _ � 8 �•• n ��:{{lv� } t'1I��.�-£x 7. `* `}S (Checl� �_ ,+ .. 1 a: ., Z. :: 1.'- f x 1. >> pine boxlor each ca#rgo�} -; £ ..s ..:. i' _ �� . .. j F Y '•�� ... - `:, �r }z: jL« i.i,�, rI Lt'�y t' i.. I x• x —x, ₹n i j� �...t ;4 c J. ,. { F` `i i i! } 4 � 1tk� .i.� .1b-,. „}I ��₹}1{ il*h^•� e. { :�. .......y., r sr ::. .r:� 3i1P ta, ;_; i ,.. Hr r : £ a._. a;..,., _i?:.: p £3.i;v;.. w... r u u>. ' ... ' ' 4 .•Y • :. t...........�;i�r }. fg ;;, : Est'm 7n _ •"•'r.'Y ur•: Ei a 3ai8di[`r r ,3'r „w� •"fi:.a k ag s •£f to:� ryi Its+}: :� RceiE fi e z _. , "e ;�... ❑ .:ti ia '"9y ❑ ! ¢;; " u C C w re .,xt ..,� , a£ 'a hL ,n V1t' ie iW r S i.w y �!.'• � iii'• ` rx t �. ! , s 41: i i -4' i.:, _£ "� : t. �.: Aggression/Cruelty to Animals / ❑ O 0 ❑ E Verbal or Physical Threatening d ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ 0 ❑ ■ Stealing ❑ ❑ ❑ 0 ❑ ❑ Self -injurious Behavior d ❑ 0 ❑ ❑ 0 ❑ Substance Abuse \ 1,,, ,.,,....: r'u( ❑ ❑ ❑ ❑ ❑ ■ Presence of Psychiatric Symptoms/ConditionsE(' ❑ CI• ❑ ❑ ■ Enuresis/Encopresis / ,L —,d,/ ❑ ❑ ❑ ❑ ❑ ■ Runaway ❑ ❑ 0 ❑ ■ • Sexual Offenses 12 ❑ ❑ ❑ 0 ❑ ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please race the behavior/intensity of conditions which create the need for services that apply to this child. 1 r,.' I Ot '' ' (Check Rating of Conditions one box for each category) Assessment Areas None Maid Mild/ Moderate Moderate' Ili It 3 ,- tt.LI , Severe Ct,minents:. Moderate. Ilili I} I 1 1i2 2 21/2 3 1/2 Inappropriate Sexual Behavior �( 12I ❑ ❑ ❑ ❑ ii❑ Disruptive Behavior ,,( N ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ IN Depressive -like Behavior d ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) dr ❑ ❑ ❑ ❑ ❑ II Emancipation ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems dr 0 0 ❑ 0 ❑ I Boundary Issues d ❑ ❑ ❑ ❑ ❑ • Requires Night Care ❑ ❑ ELI ❑ ❑ ❑ ❑ Education Eli ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family 47 ❑ ❑ ❑ r 4� �~`` I II CHILD'S OVERALL L VEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2t/2 ❑ 3 ❑ 3'/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE iSdi; l�h� "Y �� aC$M1c'{�y'�,' 'may -,y+dpidS. �:fi`i�`�'W�.v��...'i•� �rt�i'St ygilF Lt �$. County Basic Maintenance Rate 5E'sr ``"` Age 0-10...$16.32/day Age 11-14...$18.05/day Aqe 15-21...$19.27/day + Respite Care $.66/day 1+ :as $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 ?r� $23.01 +$.66 Respite Care ($23.67 day) 2 rFFg, $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 ;:? ' $29.59 +$.66 Respite Care ($30.25 day) 3 $32.88 +$.66 Respite Care ($33.54day) 3 1/2 ruK $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down rc€ $39.45 ($ +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate m g�y $29.59 +$.$ Respite Care ($30.25 day) ($ Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this O day of 20 /3 , by and between the Board of County Commissioners of Weld County, on beh if of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Carter, Jeremy and Susan, whose address is 12-04-2'43 Lti c✓ Tauglewood, Windsor, CO 80550, hereinafter referred to as, "Contractor." This Agreement Dri. covers all children placed by County with Contractor. ra, ;,'' , iag Lo WITNESSETH: '�32j WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands. and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. £Z :b V AZ sfl;,' (161 CWS-7A Individual Provider Contract Revised 6/2013 O20/4 --a 21--}d II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 • Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: B Deputy '`erk to the Approval as to Substance: WELD COUNTY DEPART OF HUMAN SERVICES The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services las demacher, Chairman Protein RACTOR: SEP 3 0 2013 rter, Jeremy and Susan 1-2n44a weod- 21 i3 Co, W-iridsol; O -8055e-- CY G \w.r C�. By: v,n'1( �aittQr) Cal 214 IS By County Director's (or designee's) Signature and Date CWS-7A Individual Provider Contract Dirgt for s (or designee's) Signature and ate 9 Revised 6/2013 UW/3- c7 v EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Carter, Jeremy and Susan, hereinafter referred to as, "Contractor." GENERAL PROVISIONS County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1556173. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑ Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: O 1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required O 2) Three times a month 03%) Three times a week or more Comments: ❑l) Once a month ❑1%) Two times month ❑ 2%) Once a week 03) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements 01) Less than a''/2 hour per day ❑1'/)'% hour a day ❑2) 1 hour a day 02 %2) 11/2-2 hours per day 03) 2%z-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week O1%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week O 3%) 21 or more hours per week Comments: ❑ 1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two timesper month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. *"Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 01) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month Exhibit "B" to the Additional Provisions 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that auuly to this child. .:ay;'::R^T.S f^:• - { 1 . F1.hE ;',..a. r A .i c•>: '.... =f{ •� ' ;..'. :: ..�:F_.i.. :_.. c ;; ._ • • 't:::: � .F..i ..;�:,--,.! . _ ...�� :„ , .. :: a .... .: ; :. _ i.:..! � .� , u . ; ' e,.s� » ...r...,. .,.,. s. r..... �.,..•T.t...�tF`:P.-�S.'x��'�'.:.ii•�..:.,t, ) .. .' htE L: .. .F s a .:~ � :., . r .-. ••`�.. •' L OY p , iL 15: ( I { or each cute LItilI .}. � w-•c'x •f 4,.�'� � _ r.. -` ?'�.�. : :Cc. . .-; ••:' ( ( 1 r -f. [rtl .. F.:i _:.�� , : :� i; !:•j7 �°{'%'.hF�. �. ;r. b E.:. 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'` r Y 'tvi �f rl „ ��:.�: ..t��'., [ a 47 '4{ .., �: ;`. �ifrz�° r �'-r'i:'_•s'::'. r 1 l Aggression/Cruelty to Animals ❑ ❑ ❑ ■ ■ • Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ 0 ❑ ❑ • ■ • Stealing ❑ ❑ 0 ❑ ❑ ❑ ■ Self -injurious Behavior ❑ 0 ❑ 0 ❑ ❑ ❑ Substance Abuse 0 ❑ ❑ ❑ 0 ❑ • Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ • Enuresis/Encopresis ❑ ❑ ❑ 0 ❑ 0 ❑ Runaway ❑ ❑ ❑ ❑ ❑ • • Sexual Offenses ❑ ❑•❑ ❑ ❑ ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 s EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that annly to this child. Rating of Conditions (Check one box for each category) Assessment Areas None 0 Mild Mild/ Moderate Moderate/ Nigh llieh,, Severe Comments: Moderate. High 1 1 1/2 2 2 1/2 3 3 1/2 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ • ■ Delinquent Behavior 0 ❑ ❑ ❑ ❑ • ■ Depressive -like Behavior ❑ ❑ ❑ ❑ •❑ • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ ❑ Emancipation ❑ ❑ 0 ❑ ❑ ❑ ❑ Eating Problems ❑•❑ ❑ ❑ ❑• Boundary Issues ❑ ❑ ❑ ❑ ❑ • ■ Requires Night Care ❑ 0 ❑ ❑ ■ ■ ■ Education ❑ ❑ ❑ ❑ ■ ■ • Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2'/2 ❑ 3 ❑ 3'/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Age 0-10...$16.32/day County Basic Maintenance Rate Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day 1 $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 $23.01 +$.66 Respite Care ($23.67 day) 2 $26.30 +$.66 Respite Care ($26.96 day) 2 112 $29.59 +$.66 Respite Care ($30.25 day) 3 $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this �3 day of / , 20 /3 , by and between the Board of County Commissioners of Weld County, on be alf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Drury, Dean and Karla, whose address is 1301 38th Ave, Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 - Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST � S'"S`"g' '" B Deput /Cler to the Board Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES CTOR: ry, Dean and Karla 1301 38th Ave Greele , CO 80634 By: The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services demacher , Chairman Protein SEP 3 0 2013 Director's (or designee's 4 ignature and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 as/S- ?2 5 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Drury, Dean and Karla, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1606578. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4`1' of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A S -7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑ Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. ❑ 3%) 7 round trips or more Comments: 01) One round trip a week ❑1'/z) 2 round trips a week ❑2%) 5 round trips a week O3) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? O Basic Maint.) No participation required ❑2) Three times a month ❑3%) Three times a week or more Comments: ❑1) Once a month ❑1'/2) Two times month ❑2%) Once a week O3) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements 01) Less than a '/z hour per day ❑1 'A)' /2 hour a day O2) 1 hour a day ❑2' 'A) 1'/z-2 hours per day O3) 2'/z-3 hours per day ❑ 3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.) No special involvement needed O2) 8 to 10 hours per week 0 3) Constant basis during awake hours Comments:. ❑1) Less than 5 hours per week ❑2%) 11 to 14 hours per week O3%) Nighttime hours 01%) 5 to 7 hours per week P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week ❑3'%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. O1,h) Face-to-face contact one time per month with child and occasional crisis intervention. ❑2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0) Not needed or provided by another source (i.e. Medicaid) O 2) 4-8 hours per month Exhibit "B" to the Additional Provisions 5 01) Less than 4 hours per month O3) 9-12 hours per month Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. 5 �{.. ff_ yla a~C r13�.AF"S.3�1tYa tit�'.lu.-, �`-�� • 3 TM. '. Lit t� lr � 'a .0.42a$.,,,\ �� 3t� )FZdtIIl, of Conditions arm a,� ' i ry),� � . . � . Chcck one box for e.ich cate o ,1, Assessment Areas Rolle Mild Mitd/ Moderate Moderate.? High I 4.... Severe Comments: Moderate. flint] 0 1 1 1/2 2 2 1/2 3 3 1/2 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ O O • Verbal or Physical Threatening O O O O IIO • Destructive of Property/Fire Setting O O ❑ O ■ ■ ■ Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ O ❑ ❑ ■ ■ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ■ ■ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ■ ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. • Rafting of Conditions (Check one box for each category) Assessment Areas None Nlitd - 1 -till/ Moderate !Underact h'h Mel> Comments: Ntodcrate. 1livfi Severe 1) 1 11/2 2 21/2 3 3 112 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ O ■ Delinquent Behavior O ❑ ❑ ❑ ❑ ■ ■ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Medical Needs• (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ■ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ■ ■ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/2 ❑ 2 ❑ 21/2 ❑ 3 031/2 I Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE County Basic Maintenance Rate Age 0-10...$16.32/day � Age 11-14...$18.05/day i≥1x a Age 15-21 $19.27/day + Respite Care $.66/day 1 ;iryo'4 it: $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 d' $23.01 +$.66 Respite Care ($23.67 day) 2 n 'l ini $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 3ya $29.59 +$.66 Respite Care ($30.25 day) 3 '�.�. $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down eas ,?) as $39.45 ($ +$. Respite Care ($40.11 day) 5; tat Assessment/Emergency Rate 1 $29.59 +$66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into thislS day of 11ht.'wst , 20 izz3, by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Erbacher, Dan and Hallie, whose address is 3850 Cheyenne Dr, Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. Any emergency. g. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their handsand affixed their seals the day and date first written above. COUNTY: ATTEST: �` — • By: Deputy '' erk to the Boar Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: ctor's ( d Date CWS-7A Individual Provider Contract RACTOR: Erbacher, Dan and Hallie 3850 Cheyenne Dr Greeley, CO 80634 By: The Board of County Commissioners of Weld ty, on behalf of the Weld County Department Services ademache , , Chairman protein SEP 3 0 2013 Director's (or designee's) Signature and Date x/)5 /3 9 Revised 6/2013 /4- 27≤S EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Erbacher, Dan and Bailie, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1546381. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access, and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A S -7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? O Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: 01) One round trip a week ❑1/) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month 011/2) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O Basic Maint.) No educational requirements ❑2) 1 hour a day ❑3'/) More that 3 hours per day Comments: 01) Less than a %2 hour per day 011/2) 1/2 hour a day 02 V2) 1'/2-2 hours per day 03) 2'/,.-3 hours per day P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week ❑1%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'%) 11 to 14 hours per week O 3) Constant basis during awake hours ❑3'/) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑3'/) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1/) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time ner month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month Exhibit "B" to the Additional Provisions 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. .... 1 :• � ( � � �• .. '.�f:f�"ris-. t.:r�`'°'' •� •�s�-• .,z.,; .r .......,,:.�..„��t.',::M>':.•.....:...•_.-•:::�:,�•'s-,:..-' :,' i.:,_ ii'' 1 %:!;H:, ..._ J .; }4 4 ,-i2-) �' .:: � F8 � �'jJ �.,.r, t>�..2 s .t•_r.• ... ��• +Ghe�k''one box .....S.:•.:'1:^. ::•ILZ:t:J...'ft:':t... ....: .L.�C.R "..........•..... .. ..S �ti: iS S:>rit.. Y :_SC.. 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' Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ O Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑Ili Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ ❑ ■ ■ Self -injurious Behavior ❑ ❑ ❑ ❑ O O ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions O ❑ ❑ El ❑ ❑ ■ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ O ❑ ❑ O O ❑ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. .. :..:.' .. g "�s r'l .._ t il .:• w^i , ..z ,i :. r,£t'.. tq y..._C' '? l t iK 0 ?Y ;@,yR,. a:i :} ;tM," dive- i +.h .i.^i .. Il :,r ;,...•_i 'dsa• `rf :fiG Mii F: i L.r. f� :d t »` a::l'a`. ..»«..t� u. ii8i. ,:«.��a._>i: _... n•�4 : . u ?'�.t... Y }.I ,t�� • .. ..._ .�.:: _ ,.. _..S.:. —w :t:^^:� •„ i.".i:.:. •'�i..? :.:"�'{�ry:,.:S. 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Y-. .._... `. ., Inappropriate Sexual Behavior ❑ El❑ ❑ ❑ . ■ Disruptive Behavior ❑ ■ ❑ ■ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ 0 Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Medical Needs (If condition is rated ❑ ❑ ❑ El • • • "severe", please complete the Medically fragile NBC) Emancipation 0 ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ El ❑ ❑ ❑ Boundary Issues ❑ ❑ 0 ❑ ❑ ❑ ■ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ • Education ❑ ■ ■ ❑ ■ ❑ ❑ Involvement with Child's Family 0 ❑ 0 ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/2 ❑ 2 ❑ 2%2 ❑ 3 ❑ 3 %2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Age 0-10...$16.32/day County Basic Maintenance Rate 1 Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 $23.01 +$.66 Respite Care ($23.67 day) 2 $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 $29.59 +$.66 Respite Care ($30.25 day) 3 $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this r day of GNU f , 20 , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Fritz, Nancy, whose address is 3925 Stampede Dr., Evans, CO 80620, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 aoi3- 022e5 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department.. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. Any emergency. g. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To frilly comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it hasverified that Contractor does not employ any illegal. aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST�su�-a.��- Deputy '' erk to Approval as to Substanc WELD COUNTY DEPAR OF HUMAN SERVICES By: The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services cogviv auLi uglas R. demacher, Chairman Plata* NTRACTOR: Fritz, Nancy 3925 Stampede Dr. Evans, CO 80620 SEP3O2013 /- By: J /1"s Director's (or desig s Signature and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 ae/. -075 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Fritz, Nancy, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1539167. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. ❑3'/:) 7 round trips or more Comments: 2 �I) One round trip a week ❑1%) 2 round trips a week %) 5 round trips a week O3) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ® Basic Maint.) No participation required ❑2) Three times a month ❑3'/:) Three times a week or more Comments: DI) Once a month ❑1%) Two times month O2%) Once a week O3) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? Q Basic Maint.) No educational requirements O2) 1 hour a day O3%) More that 3 hours per day Comments: ❑1) Less than a''/3 hour per day 01%) 'A hour a day O2 'A) 1'/z-2 hours per day O3) 2'A-3 hours per day P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.) No special involvement needed ❑2) 8 to 10 hours per week 3) Constant basis during awake hours Comments: 01) Less than 5 hours per week ❑2%%) 11 to 14 hours per week O3%) Nighttime hours 01%) 5 to 7 hours per week P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week Ell) 8 to 10 hours per week Lii'%) 21 or more hours per week Comments: O1)3 to 4 hours per week 01%) 5 to 7 hours per week [12%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑l) Face-to-face contact one time per month with child and minimal crisis intervention. ®1%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3/) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T L How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) RJ2) 4-8 hours per month Exhibit "B" to the Additional Provisions 5 O1) Less than 4 hours per month O3) 9-12 hours per month Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services tha . _..,p . i..__ ' ' �� c fr Rating of Conditions P. A -� �; �i -(�� (Check one box for each category) .u�� { 7 "s"xaa, IL .�Gs.i'x�.. i� ��. _ . , �z5v7v : _..._. 1 '.t!?:+'. t"nli3 ' n .,. wit. .� a ism... '� 1��`-, i ,.,..R.9r . iiip.. L. �.�' w't.`s _ �� :., -' ) - lc "I Y,t� Z'_.... 1� tee!![+( .. ''Sues q , , _ '1 - , ,A.,...,- Assessment Areas None 19iId NIikd! Moderate Moderate' High Hi.h, C-ontinents: 4� U „'°�..,�afi=,:-14; Moderate. Hirsh Severe m �.aRt_; 1 1 1,.2 2 2 1/2 3 3 1/2 Aggression/Cruelty to Animals gl ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ M 0 ❑ 0 ❑ ❑ Destructive of Property/Fire Setting 0 ❑ ❑ ❑ ■ ■ ■ Stealing ❑ ❑ ❑ ❑fa❑ ■ Self -injurious Behavior IN ❑ ❑ ❑ ■ ■ ■ Substance Abuse Q ❑ ❑•❑ ■ ■ Presence of Psychiatric Symptoms/ConditionsIll❑ ❑ ❑ ❑ ❑ ■ Enuresis/Encopresis ❑ Li ❑ ❑ ❑ ■ Frl Runaway ❑ ❑ ❑ ❑ ❑ ■ Sexual Offenses ig ❑ ❑ ❑ ■ ■ ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED ('lease rate the behavior/intensity of conditions which create the need for services that apply to this child. :Rating of Conditions (Check one box for each category) Assessment Areas None '4lild Mild/ 'Moderate Moderate! I�lio�lr High Continents: Moderate. Molt Seeere 0 1 1 1/2 2 2 1/2 3 3 1/2 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ .1 Disruptive Behavior ❑ ❑ O ❑ ❑ ■ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ■ Depressive -like Behavior O ❑ O ❑ ❑ ❑ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) E ❑ O ❑ ❑ ❑ O Emancipation ig ❑ O ❑ ❑ ❑ O Eating Problems 2 ❑ ❑ ❑ ❑ ■ ■ Boundary Issues ❑ O ❑VI al ■ • Requires Night Care El ❑ ❑ ❑ ❑ ❑ ❑ Education O ❑ ❑ O ❑ O • Involvement with Child's Family K ❑ O ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1 %2 ❑ 2 ❑ 21/2 ❑ 3 ❑ 31/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE j1E+i` :.t.°a�t T 4 ... a I� mi'i County Basic Maintenance Rate a�3 Age 0-10...$16.32/day Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day 1 $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 $23.01 +$.66 Respite Care ($23.67 day) 2 �s=;@ 4ai $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 `=sj $29.59 +$.66 Respite Care ($30.25 day) 3 enn $32.88 +$.66 Respite Care ($33.54day) 3 1/2 y'}! $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down t; a. ;z;: �'- $39.45 +$.66 Respite Care ($40.11 day) AssessmeRn =emergency $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this oi3 day of ` , 20 ),3 , by and between the Board of County Commissioners of Weld County, on be alf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Froggatte, Samuel and Rachelle, whose address is 213 N 52nd Ave, Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEa4' B Deputy ' k to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: TRACTOR: Froggatte, Samuel and Rachelle 213 N 52nd Ave Gr ley, CO 0634 rector's (or design and Date The Board of County Commissioners of Weld County, on behalf of the Weld County Department uman Services s Rademacher Chairman Protem SEP302013 CWS-7A Individual Provider Contract 9 Revised 6/2013 °i%S-725 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Froggatte, Samuel and Rachelle, hereinafter referred to as, "Contractor." GENERAL PROVISIONS County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1601426. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P I. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑ Basic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. ❑3%:) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month ❑1%) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑1) Less than a 1/2 hour per day 01%) % hour a day 02) 1 hour a day 02 %) I %-2 hours per day 03) 2'/r3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week ❑1'/z) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week O 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: 01)3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑ 1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O 0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month Exhibit "B" to the Additional Provisions 01) Less than 4 hours per month 03) 9-12 hours per month 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions (Check one box for each category ,'a� i' �F � �� '. zl 9 AsSeSSTnent Areas Noire Mild Mild/ Moderate Noderate ilirih High, Severe. COMM COS: Moderate. liinh 0 I. 1 1/2 2 2 1/2 3 3 1/2 Aggression/Cruelty to Animals ❑ ❑ ❑ ■ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ • • • Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ■ Stealing ❑ ❑ ■ •❑ ❑ ❑ Self -injurious Behavior ❑ ❑ • ■ • ❑ ❑ Substance Abuse ❑ ■ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ■ ■ ■ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ • ❑ ❑ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior'intensity of conditions which create the need for services that apply to this child. � hp A E,,.,i� �,, �h� �zfi'�ST,lY �a Waling of �,,{)editions t y ... ' t � I � ,I �lig (Check one box for each category) i .F.. 3UT L Ora .� _, _•_ ; ; __ �, v. .ti s ) y �a , -. S'y k � .�: ,,,..� Assessment Areas None .Mild Mild; — Moderato Moderate: than Ilieh- Comments: l derate. H12h Severe 0 1 1 I/2 2 2 1/2 3 3 1/2 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive -like Behavior ❑ ❑ 0 ❑ ❑ 0 • Medical Needs (If condition is rated "severe', please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ ❑ ■ ■ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ■ Boundary Issues ❑ ❑ 0 ❑ ❑ ❑ ❑ Requires Night Care D ❑ ❑ ❑ ❑ ■ ■ Education ❑ ❑ ❑ ❑ ❑ ■ ■ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 O 1'/2 ❑ 2 ❑ 21/2 ❑ 3 ❑ 3Y2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 'fit 'z t � "h 4� 14 ryS �F��M�� County Basic Maintenance Rate i ^1:'! 4, ; R Lk��,l�l� x ti� hl➢ k'!. y��'k P iS y�y2��yL `3it��Ap• � � l�k`k' ilki ®1�� .� '�';},'�'g�, .,':µF _� `�l ��ft Age 0-10...$16.32/day Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 $23.01 +$.66 Respite Care ($23.67 day) 2 �4m $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 $29.59 +$.66 Respite Care ($30.25 day) 3 (r` s $32.88 +$,66 Respite Care ($33.54day) 3 1/2 �.,� $36.16 +$,66 Respite Care ($36.82 day) 4 RCCF Drop Down lrrrc $39.45 +$,66 Respite Care ($40.11 day) at it ii,it Assessment/Emergency Rate " $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into thisr,23 day of d , 20 )3 , by and between the Board of County Commissioners of Weld County, on beh f of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Gomez, Oswald and Christina, whose address is 7226 Matheson Dr., Fort Collins, CO 80525, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTESTiVGa.. The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services BY „�; ��!��ry By: Z"�,43 b�4hQCAUC Deputy' erk toouglas Rademacher, Chairman Protein Approval as to Substan WELD COUNTY DEPA OF HUMAN SERVICES By: BZ :L 'd CZ 91W E107 CWS-7A Individual Provider Contract ONTRACTOR: Gomez, Oswald and Christina 7226 Matheson Dr. Fort Collins, CO 80525 By: SEP 3 0 2013 Director's (or designee's) Signature and Date 9 Revised 6/2013 O,19S- 07245 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Gomez, Oswald and Christina, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1588508. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the e of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A S -7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. ❑3Y:) 7 round trips or more Comments: ❑l) One round trip a week ❑1%z) 2 round trips a week O2%) 5 round trips a week O3) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? O Basic Maint.) No participation required O2) Three times a month O3%) Three times a week or more Comments: ❑1) Once a month ❑l%) Two times month O2%) Once a week O3) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O Basic Maint.) No educational requirements DI) Less than a''/3 hour per day ❑1%) Y hour a day O2) 1 hour a day O2 %) 1'/z-2 hours per day O3) 2%:-3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑l) Less than 5 hours per week O1%) 5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑l) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month O2) 4-8 hours per month O3) 9-12 hours per month Exhibit "B" to the Additional Provisions 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior!intensity of conditions which create the need for services that anoly to this child. Rating of Conditions (Cheek one box for each category) Assessment Areas None Mild Mild/ Ntoderale N1oderatel ilia)! Ilia Severe Comments: � �F NI°dentte. Ili"It 0 1 1 1/2 2 2 1/2 3 3112 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ • • Verbal or Physical Threatening ❑ ❑ ❑ ❑ ■ • • Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ • Stealing ❑•❑ ❑ ❑ ■ ■ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ■ ■ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ■ • Enuresis/Encopresis ❑ 0 ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ 0 ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ 0 ❑ ❑ ❑ ❑ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that auuly to this child. Rating; of Conditions (Check one box for each category) Assessn►ent Areas None Mild Mild/ Moderate Modern tei Itr`'lI high% Comments: ''' ' N• 'i . _ Moderate. Molt Severe 4 -ii: 0 11 1/2 2 2 1/2 3 3 I%2 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ■ ■ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ O ❑ ❑ ❑ ❑ Emancipation ❑ O ❑ ❑ ❑ ❑ ■ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ O ❑ ❑ ■ ■ Requires Night Care ❑ ❑ ❑ ❑ • • ■ Education ❑ ❑ ❑ ❑ O ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 El 11/2 El 2 ❑ 2'/2 ❑ 3 ❑ 3'/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Age 0-10...$16.32/day County Basic Maintenance Rate 1 Id •Mainter /Respite' Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 $23.01 +$.66 Respite Care ($23.67 day) 2 $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 $29.59 +$.66 Respite Care ($30.25 day) 3 $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this day of , 20 by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Hanke, Mark and Kerri, whose address is 2796 Old Farm Ave NW, Salem, OR 97304, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract I Revised 6/2013 O?e,/6- 7Z3 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with the Needs Based Care Addendum 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 prohibiting the periodic amending of this Agreement and Addendum in writing, if agreed to by both parties. This Agreement and Addendum are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: Y.. By' Li g, Deputy fire to th Approval as to Substance: WELD COUNTY DEPART OF HUMAN SERVICES By: The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services e"'S LC3 mo (L. glas Rldemache , Chairman Protem TRACTOR: anke, Mark and Kerri 2796 Old Farm Ave NW Salem, OR 97304 By: SEP 3 0 2013 Director's (or designee's) Signature and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this € S day of At.16 , 20 13, by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Heard, John and Kimberly, whose address is 109 Hunters Cove Dr., Mead, CO 80542, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 043-- 7Z -A5 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST```' By: Deputy C #ck to th Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: The Board of County Commissioners of Weld County, on behalf of the Weld County Department f Human Services as Rademacher, Chairman Protem CONTRACTOR: Heard, John and Kimberly 109 Hunters Cove Dr. Mead, CO 80542 By: SEP 3 0 2013 Director's (or designee's) Signature and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this day of Ite4:4_ 20 is , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Jacobsen, Tara and John, whose address is 11655 Grove Stree, Westminster, CO 80031., hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 23, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified' under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A S -7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST`:�A'�x" By trikiL 4 Deputy orerk to the i, Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services rt�y r s kivin ci ` - las IYademacher, Chairman Protein TRACTOR: SEP 3 0 2013 Jacobsen, Tara and John 11655 Grove Stree Westminster, CO 80031 Director's (or designee' �nDate WM 13 (3 gnature CWS-7A Individual Provider Contract 9 Revised 6/2013 dwi,5- a7‘5 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Jacobsen, Tara and John, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1615091. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Depat lucent of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week O2%) 5 round trips a week O3) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required O2) Three times a month O3%) Three times a week or more Comments: 01) Once a month O1%) Two times month O2%) Once a week O3) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements DI) Less than a %2 hour per day 01%) % hour a day ❑2) 1 hour a day O2 %) 1%-2 hours per day O3) 2%-3 hours per day O3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: 01) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week O3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. O1%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0) Not needed or provided by another source (i.e. Medicaid) O2) 4-8 hours per month Exhibit "B" to the Additional Provisions 5 ❑1) Less than 4 hours per month O3) 9-12 hours per month Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions (C heck one box for each category) , •a'r ,. Assessment Areas None Mild %I Mild/ Moderate Moderate/ Hid! ti,ci,1 Severe ?sb � .., Moderate. High tl 11 12 2 2 1 /2_ 3 3 1/2 Aggression/Cruelty to Animals ❑ O ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ■ ■ ❑ ❑ ❑ ■ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ ❑III ❑ Self -injurious Behavior ❑ ❑ ■ ❑ ■ ❑ ❑ Substance Abuse ❑ O ■ ❑ ❑ ■ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ • ■ ❑ • ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ■ ■ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ■ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions -. (Check one box for each category) : Assessment Areas None Mild - Mild, Moderate Moderatel Ili h I1. ,_ Severe Continents: Moderate. Ile'It 0 1 1112 2 21,2 3 • r Att `: Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Disruptive Behavior ❑ ❑ 0 ❑ ❑ ■ IN Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ El ❑ ❑ ❑ ❑ . Emancipation ❑ ❑ 0 ❑ ❑ ❑ ■ Eating Problems ❑ ❑ ❑ ❑ ❑ ■ ■ Boundary Issues ❑ El ❑ ❑ ❑ ■ • Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ■ Education ❑ ❑ ❑ ❑ ■ ■ ■ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/z ❑ 2 El 21/2 ❑ 3 3'/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE #. i 4'd4. d ID i 3 5 �y gyp+. d,i'—:� County Basic Maintenance Rate Age 0-10...$16.32/day Age 11-14...$18.05/day e` Age 15-21...$19.27/day s.a + Respite Care $.66/day 1 ° $19.73 +$.66 Respite Care ($20.39 day) 1 1/2`! ph ;cam $23.01 +$.66 Respite Care ($23.67 day) 2 $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 ''. $29.59 +$.66 Respite Care ($30.25 day) 3 :::,.�, $32.88 +$.66 Respite Care ($33.54day) 31/2 Ja x $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down + $39.45 +$.66 Respite Care ($40.11 day) �u Assessment/Emergency Rate ru e `+ $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this () day of 20 i3, by and between the Board of County Commissioners of Weld County, on b alf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Kirchoefer, John and Erin, whose address is 1420 Snipe Lane, Fort Collins, CO 80524, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is `renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST B 11L1L/_'_ Deputy terk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES CWS-7A Individual Provider Contract The Board of County Commissioners of Weld County, on behalf of the Weld County Department f Human Services COLVAci ONTRACTOR: Kirchoefer, John and Erin 1420 Snipe Lane Fort Collins, CO 80524 By:f' `� CL_ 9 / Director's (e' designee's and Date 'chairman Pwtem SEP 3 0 2013 0/3 9 Revised 6/2013 020/2- a 245 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Kirchoefer, John and Erin, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1631599. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4ti' of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A S -7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information Weekly'on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week ❑2'/a) 5 round trips a week O3) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required O2) Three times a month ❑3%) Three times a week or more Comments: 01) Once a month 01%) Two times month O2%) Once a week ❑3) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements DI) Less than a Y hour per day ❑1'/) Y hour a day O2) 1 hour a day O2 %) 1'/:-2 hours per day O3) 2%r3 hours per day O3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week DI %) 5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) 11 to 14 hours per week O 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) DI) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1/) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) O2) 4-8 hours per month Exhibit "B" to the Additional Provisions 5 01) Less than 4 hours per month ❑3) 9-12 hours per month Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. IPa �,i ' 4 � ti gen.�� 'w. JS' i',.,, ^a. ' D 4 aS P.4' rtJLTi- Rating of Conditions (Check one box for each category) Assessment Areas _ OIR! Mild ?Flikli Moderatetliih Moderate! High High' COlninctitS: 4:-.F. 4,r2.. Moderate. 2 112 Severe 0 1 1 1/2 2 3 3 112 Aggression/Cruelty to Animals ❑ ❑•❑ ❑ ❑ • Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ■ ■ Stealing ❑ ❑ ❑ ❑ ❑ ■ ■ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ■ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ O ❑ ❑ ❑ ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this c Rating of Conditions (Check one box for each category) Assessment Areas None Mild y1ild, Moderate Moderate/ lli.'h ili Severe Continents: 1007. Moderate. High f) I 11/2 2 2112 3 31,2 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Delinquent Behavior ❑ ❑ 0 ❑ ❑ ❑ ❑ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ill- ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ 0 ❑ ❑ ❑ ❑ • Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ■ Requires Night Care ❑ ❑ ❑ ❑ ❑ • ■ Education ❑ ❑ ❑ ❑ ❑ ❑ • Involvement with Child's Family I ❑ ❑ ❑ ❑ ❑ ■ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ l'/2 ❑ 2 ❑ 2%2 ❑ 3 ❑ 3'/ Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE per.® }3s�"1i43jicP � ,# B � County Basic Maintenance Rate Age 0-10...$16.32/day Age 11-14...$18.05/day " v A,le 15-21...$19.27/day + Respite Care $.66/day 1 1 $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 jai $23.01 +$.66 Respite Care ($23.67 day) 2 z $26.30 *$.66 Respite Care ($26.96 day) 2 1/2 $29.59 +$.66 Respite Care ($30.25 day) 3 fit t. $32.88 +$.66 Respite Care ($33.54day) 3 1/2 '( $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down o�=`t $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate $29.59 *$.66 Respite Care ($30 25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT. FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this /43 day of ��, 20 / 3 , by and between the Board of County Commissioners of Weld County, on be if of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Kniss, Kevin and Kelly, whose address is 13089 Marion Dr., Thornton, CO 80241-1936, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CD 0 �d CWS-7A S -7A Individual Provider Contract Revised 6/2013 (9e/i- 07X5 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 .III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposesfor at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 . WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: B i 2.{, i Deputy 'trk to the B Approval as to Substance: WELD COUNTY DEPARTMEN OF HUMAN SERVICES By: CWS-7A Individual Provider Contract The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services taas Rad mac Chairman TRACTOR: SEP 3 0 2013 iss, Kevin and Kelly 13089 Marion Dr. Thornton, CO 80241-1936 By designee s) gnature and Date 7/1/3 9 Revised 6/2013 Q75Z5 d EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Kniss, Kevin and Kelly, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1524303. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. O3%) 7 round trips or more Comments: DI) One round trip a week 1'h) 2 round trips a week ❑2'/:) 5 round trips a week O3) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required O2) Three times a month O3%) Three times a week or more Comments: ❑I) Once a month ❑a) Two times month O2%) Once a week Z-3) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? asic Maint.) No educational requirements ❑1) Less than a % hour per day O1%) '/2 hour a day 2) 1 hour a day O2 %) 1'%-2 hours per day O3) 2'/z-3 hours per day O3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.) No special involvement needed ❑ 8 to 10 hours per week © 3) Constant basis during awake hours Comments: ❑1) Less than 5 hours per week O2%) 11 to 14 hours per week [r. /2) Nighttime hours 01%) 5 to 7 hours per week P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? El Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week O3%) 21 or more hours per week Comments: A 1. How often is CPA/County case management required? (Does not include therapy) DBasic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. &I%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month IV13) 9-12 hours per month Exhibit "B" to the Additional Provisions 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apple to this child. Rating of Conditions4,.� (Check one box for each category s�', ,,g �? Idlitlli� u u r _ r , l' ��• ...tia'hi' "�:',3 °`', r . s', Assessment Areas Nom' NTild NUM/ Moderate Moderate" High tr ik Ili Severe Comments: 'n `srcr,lar N'ioderate. High 2lit ft I . 1 lit 2 31/2 Aggression/Cruelty to Animals 81❑ ❑ ❑ ❑ ❑ ■ Verbal or Physical Threatening ❑ ❑ ❑ .K ❑ ❑ El Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ I, ■ Stealing ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious. Behavior ❑ 12: ❑ ❑ ❑ ❑ ■ Substance Abuse •IK❑ ❑ El ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ 51 ❑ ❑ ■ Enuresis/Encopresis N" ❑ ❑ ❑ I I ■ Runaway ❑ ,ter la ❑ ❑ ❑ ❑ ❑ Sexual Offenses O ❑ ❑ ix ❑ ■ • Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. 11 �.r>�;1, . Rating of Conditions .'g,+`FiF u 3�a�` r& 1 " ti• (Cheek. one box for each category) '�. t'g:IF r''ic� �, ta�m« �,,rr 'r i vn ; . \ .• acSe .,t,, � € e. 4 r �•'V�i.^iT.i": ui.i Y.�.+ `3�'-'i.'..•.k�`�.�R'�� r• Assessment Areas None Mild Mild/ Moderate Moderate/ nigh High/ Cotntnents: Moderate. Itiglt Severe (I 1 11/2 2 2 1/2 3 3 1/2 Inappropriate Sexual Behavior ❑ ❑ O ❑ ❑ t ❑ Disruptive Behavior O ❑ ❑ ❑ki❑ ❑ Delinquent Behavior ❑ ❑ ❑ g ❑ O O Depressive -like Behavior ❑ ❑ g ❑ O O ❑ Medical Needs (lf is rated "severe", please complete the Medically fragile NBC) Z ❑ O ❑ ❑ ❑• Emancipation ' O ❑ O ❑ ❑ ■ Eating Problems ( X ❑ ❑ ❑ O ■ ■ Boundary Issues ❑ ❑ ❑ixf❑ O O Requires Night Care ❑ O ❑ 0 ❑ ❑ ❑ Education ❑ ❑ ❑ O ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 O 1'/2 ❑ 2 ❑ 21/2 ❑ 3 ❑ 31/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE �"' le..ii fiy"'� � 5• 3 � r hh v ati .sy� Frr by ®r Tu'i C £� Y� f ILYtfl�' County Basic Maintenance Rate Age 0-10...$16.32/day Age 11-14...$18.05/day S=`. Age 15-21...$19.27/day + Respite Care $.66/day 1:. $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 $23.01 +$.66 Respite Care ($23.67 day) 2 $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 E: $29.59 +$.66 Respite Care ($30.25 day) 3 fi $32.88 +$.66 Respite Care ($33.54day) 3 1/2 sue; $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down asr� $39.45 +$.66 Respite Care ($40.11 day) it : n Assessment/Emergency Rate $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this j I day of 20 /3 , by and between the Board of County Commissioners of Weld County, on be alf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Maronek, Dennis and Patricia, whose address is 4860 Eagle Crest Blvd, Firestone, CO 80504, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 c 9/3 a7‘:„.5 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST s-c5°""`dr B Deputy perk to the B Approval as to Substance: WELD COUNTY DEPARTMEN OF HUMAN SERVICES CWS-7A Individual Provider Contract The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services las Rademache TRACTOR: Wig CAA Chairman protein SEP 3 0 2013 Maronek, Dennis and Patricia 4860 Eagle Crest Blvd Firestone CO 80504 I444M147 By: /ec it t2<Ce:> A al4241-9/: Director's (or designee's) Signature and Date 9 Revised 6/2013 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Maronek, Dennis and Patricia, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1520627. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or perfouning a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. ❑3%) 7 round trips or more Comments: ❑1) One round trip a week ®1'/:) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more Comments: N1) Once a month 01%) Two times month ❑2%) Once a week 03) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑1) Less than a''/2 hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) 1'/r2 hours per day 03) 2'/-3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01,1/4)5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 01) Less than 4 hours per month [S],2) 4-8 hours per month 03) 9-12 hours per month Exhibit "B" to the Additional Provisions 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services tha Rating of Conditions,., �_>n .` (Check one box for each category) .( + II'° "itik nN 4al..4 � �l � k :ue let1, Assessment Areas None %iild Mild,' Moderate M0(iefater High, 111��b Comments: llotierate. Malt Severe 0 1 1 1/2 2 2 1/2 3 3 1/2 Aggression/Cruelty to Animals ❑ N ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening N ❑ ❑ ❑ ❑ ❑ ■ Destructive of Property/Fire Setting ❑ q ❑ ❑ ❑ ❑ il Stealing ❑ ❑ ❑ 0 ❑ ❑ Self -injurious Behavior 151, 0 ❑ ❑ ❑ ■ ■ Substance Abuse in ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions a ❑ ❑ ❑ ❑ ❑ ■ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ■ Runaway ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this chit Rating of Conditions (Check one box for each category) Assessment Areas 'None Mild 'Mild; 1lodersie. Mloderxte Moderate/ Moil High" Comments: High Severe 0 I 1 1/2 2 2 1/2 3 3 1/2 Inappropriate Sexual Behavior % ❑ ❑ ❑ ❑ ■ ■ Disruptive Behavior ® ❑ ❑ ❑ ❑ ❑ ■ Delinquent Behavior ❑ ❑ ❑ 0 ❑ ❑ M Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) E ❑•❑ ❑ ❑ • Emancipation q, ❑ ❑ ❑ ❑ ■ ■ Eating Problems S. ❑ ❑ ❑ ❑ ■ ■ Boundary Issues ❑ Q ❑ ❑ 0 ■ ■ Requires Night Care 0 F] ❑ ❑ ❑ ❑ ■ Education ❑ ❑ ❑ 0 0 A ■ Involvement with Child's Family gl ❑ ❑ ❑ ❑ ❑ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/2 12 El 2'/2 El 3 ❑ 3'/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE TO rt� .47 • t1�E33�@ County Basic Maintenance Rate Age 0-10...$16.32/day Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day 1 '">dr p;mm $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 ' $23.01 +$.66 Respite Care ($23.67 day) 2 -;r s= $26.30 +$.66 Respite Care -($26.96 day) 2 1/2 Kx tt q � v4 i $29.59 +$.66 Respite Care ($30.25 day) 3 ski $32.86 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down - $39.45 +$.66 Respite Care ($40.11 day) a''=I awl $29.59 +$.66 Res rte Care p ($30.25 day) enc Assessment/Emer Rate 9 y Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this // day of , 20 43, by and between the Board of County Commissioners of Weld County, on be alf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and James & Tammy McCreery, whose address is 120 Maple Ave , Eaton, CO 80615, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from JZ/ti /, j0/3 /3 , to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 07o/3-02,45 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. Any emergency. g. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 • N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q• Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: By. LJAI __ 4 Deputy Cl rk to the Approval as to Substance: WELD COUNTY DEPARTME OF HUMAN SERVICES By: CWS-7A Individual Provider Contract The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services glas ' ademache , Chairman Protein SEP302013 TRACTOR: James & Tammy McCreery 120 maple Ave Eaton, j 80615 By Director' • (or designee's) 'gna e and Date 9 Revised 6/2013 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and James & Tammy McCreery, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1612890. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4`h of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? Basic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. ❑3%) 7 round trips or more Comments: ❑1) One round trip a week ❑1%:) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? 0 Basic Maint.) No participation required 02) Three times a month ❑3%) Three times a week or more Comments: O1) Once a month ❑1%) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑2) 1 hour a day 03%) More that 3 hours per day Comments: ❑1) Less than a %x hour per day O1%) 1/2 hour a day 02 %) 1'/-2 hours per day 03) 2'/z-3 hours per day P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 02) 8 to 10 hours per week 0 3) Constant basis during awake hours Comments: ❑ 1) Less than 5 hours per week 02%) 11 to 14 hours per week ❑3%:) Nighttime hours 01%) 5 to 7 hours per week P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? 0 Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑3'/:) 21 or more hours per week Comments: ❑ 1) 3 to 4 hours per week ❑1%) 5 to 7 hours per week ❑2%:) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) Ell) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month Exhibit "B" to the Additional Provisions 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Aggression/Cruelty to Animals ;Moderate 2 • ' 2 1/2 ''.• .y Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing o Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses Exhibit "B" to the Additional Provisions 6 Revised 6/2013 R " Ra EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. :z ,c+WWr {Check Ratigxof, o b ondt�o eg for each ca ory) -.Tr.a..t3s'S ;•'_ 1 �� ' ° ,`i iyx^ `: .14s ;, z" SVvere 1. . e5$ �' �,, ejs r. MO' ... .,,. �l Moderate Moderat High 2 1/2 _ � 1I*"h 3 h, 0111111 '' e t ` MpdeIr te; n 0se' 11/2 2 Inappropriate Sexual Behavior ❑ ❑ ❑ O ■ ■ ■ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ O O Delinquent Behavior ❑ ❑ ❑ ❑ ❑• O Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ ❑ Emancipation O ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues O ❑ ❑ ❑ ❑ ❑ • Requires Night Care ❑ ❑•❑ O ❑ • Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) El 0 ❑ 1 El 11/2 ❑ 2 ❑ 2%z El 3 ❑ 31/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 9RECOMMENDED LEVEL OF SE '' e� r G�O'�ITRAC,TOR RATE - P1 - PS _ Level i iidtMaintenera it delta County Basic Maintenance Rate Age 0-10...$16.32/day Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day 1 $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 $23.01 +$.66 Respite Care ($23.67 day) 2 $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 $29.59 +$.66 Respite Care ($30.25 day) 3 $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this 9 -14 -day of \i1 of -A , 20 15 , by and between the Board of County Commissioners of Weld County, on bialf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and McNear, Nikki, whose address is 1220 N. Grant Ave, Loveland, CO 80537, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 c2e/3"x%45 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in pail, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to teuninating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: B Deputy to the Approval as to Substance: WELD COUNTY DEPARTME OF HUMAN SERVICES By: my Direc iature s (o ate CWS-7A Individual Provider Contract The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services CA4LA—) las R:demacher Chairman ProtBRI TRACTOR: eNear, Nikki 1220 N. Grant Ave Loveland, CO 80537 By: SEP 3 0 2013 Director's (or designee's) Signature and Date 9 Revised 6/2013 072)/3- 2‘..5 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this day of , 20 /3 , by and between the Board of County Commissioners of Weld County, on be alf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Mena, David and Marie, whose address is 2905 41st Ave, Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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 C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 f WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST `g"- B Deputy ' erk to the Bo Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: CWS-7A Individual Provider Contract The Board of County Commissioners of Weld County, on behalf of the Weld County Department uman Services RACTOR: Mena, David and Marie 2905 41st Ave Greeley, CO 80634 By: % (^. fir ctor's (or designeejs) Signature and Date airman Protein SEP 3 0 2013 9 Revised 6/2013 aces- 7e EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Mena, David and Marie, hereinafter refereed to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1510691. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A S -7A 2 Revised 6/2013 . CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A S -7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week ❑I'A) 2 round trips a week ❑2'A) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? O Basic Maint.) No participation required ❑1) Once a month 011/2) Two times month 02) Three times a month 02%) Once a week 03) Two times a week ❑3%,) Three times a week or more Comments: P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑2) 1 hour a day ❑3%) More that 3 hours per day Comments: DI) Less than a'/:hour per day 01%) % hour a day 02 %) 11/4-2 hours per day 03) 2'h-3 hours per day P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 011/4) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week O 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1/) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1 /) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month Exhibit "B" to the Additional Provisions 5 DI) Less than 4 hours per month ❑3) 9-12 hours per month Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply Rating of Conditions (Cheek one box for each category) Assessment Areas Nine Mild Mild/ Muderaic Moderated High 1(i h ~were Comments: Moderate. High 0 I 11/2 2 21/2 . 3 :.' 31/2 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ • Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ • Stealing ❑ ❑ ❑ 0 ❑ ❑ ❑ Self -injurious Behavior ❑ ❑ ❑ ❑ 0 ❑ ■ Substance Abuse ❑ ❑ ❑ 0 ❑ ❑ ■ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ 0 Enuresis/Encopresis ❑ 0 ❑ ❑ ❑ 0 ■ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ■ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. i_ cE C ..r rc 1 1 �Ij �. Ji3:::?i: 1 }:f � 3 �.�.'ir,C a Wt_:..i .3�i�� .:f::^" . e ♦ ,r .� 7. edy '4'7.,� g..�� 4 .aa3•;,fr�.i.; P ,.,;Tt'� ��t-L- r - , i.'n::.s `! a { � II; . Fy 1� 4 x7?' �-i f ( 1! � '� ,{ ! F� ,4 � #J �.E� (Chef ! y]�,, -t Cx llil :' .r.� tai i .y' ..,4�.�'k c, f �r .. t '�G y ,] {. ndit}'SIIL C-r�' oions 'E Siit a catch '�atg�E. 4 u � t i d I t t, LA 1 1 1ni i.z.$ ,+{ -I • .R '.. C i. ..z?fr 1:.E- i 1, . i f ti. , � � i . 4 Ltrr�r:rev.....C i �l L� n•� 1:.:.,-*...,- U Y�{.-'E'`r 1 1, 'IJ C 1 �•r i. is {; �' 4 . ( ly ^ �i 4 I i y t E i! ! �' _�' '� `r `rrt 1!u'zl :f .i3:;6'.'�" , _' G ,i to - - ,. 3 ;: : -" % Iild 1' 7, Mi i_ ` Moderate . .", Moderate .-' High . f ;'Severe '.F I t .Ty : r Comments ii--rr - Y .r.�' : 'Moderate LEG 1112_` 2 21/2 3 _31/ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ■ ■ ■ Disruptive Behavior ❑ ❑ ❑ 0 ❑ ■ ■ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ •❑ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑• • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ 0 ❑ ❑ ■ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ■ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ■ Education ❑ ❑ ❑ ❑ ❑ ❑ ■ Involvement with Child's Family ❑ El 0 ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 3''/ Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ryk��4� r/ y i a S° 4ihxyt'F�i��.. s,•,...�'ria. ik45�`" "�s i. r ®gam &iky aa.1 Ya e� ems.. ° � r'�'3a�� County Basic Maintenance Rate Age 0-10...$16.32/day Age 11-14...$18.05/day g Age 15-21...$19.27/day + Respite Care $.66/day 1,' Uy $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 $23.01 +$.66 Respite Care ($23.67 day) 2 ' sa $26.30 +$.66 Respite Care ($26.96 day) 1/2 g $29.59 +$.66 Respite Care Respite ($30.25 day) 3 $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down ym- $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate a $29.59 +$66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this // day of , 20 /3 , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Pierce, Larry and Kris, whose address is 3017 54th Ave., Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 &2' - Mff 5 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: I. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: The Board of County Commissioners of Weld c� County, on behalf of the Weld County Department ATTEST Any >y�( JL _ of Human Services B Deputy Verk to the Approval as to Substance: WELD COUNTY DEPART OF HUMAN SERVICES By: SEP3O2013 Pierce, Larry and Kris 3017 54th Ave. Greeley, CO 80634 By: a- _ Director's (or designee's) Signature and Date 94/13 '(3 i(3 CWS-7A Individual Provider Contract 9 Revised 6/2013 Z/3 a 9Z.5' EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Pierce, Larry and Kris, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1586620. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Depattuient Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required ❑2) Three times a month 03%) Three times a week or more Comments: O1) Once a month 01%) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? 0 Basic Maint.) No educational requirements ❑2) 1 hour a day 03%) More that 3 hours per day Comments: ❑ l) Less than a ''/z hour per day 01%) % hour a day 02 %) 11/2-2 hours per day 03) 2'/-3 hours per day P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed O1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week 0 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week 03) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Malta.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO) Not needed or provided by another source (i.e. Medicaid) ❑I) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month Exhibit "B" to the Additional Provisions 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that annly to this child. Rating of Conditions ** (Check one box for each category} r,{f eb,. .. i a�a�� yn . r4i e 777 y n• 5 Assessment Areas Notre. Niiici Mild/ Moderate 1oder:He, High Ili.=Iv Comments: Modtrale. High Severe {1 1 t 1/2 2 2 1/2 3 3 1/2 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ■ • Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ■ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ • Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Substance Abuse ❑ ❑ ❑ ❑ ❑ • • Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ■ Enuresis/Encopresis ❑ ❑ ❑ ❑ ■ ■ ■ Runaway ❑•❑•❑ ❑ • Sexual Offenses ❑ ❑ ❑ ❑ ❑ • • Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions (Check one box for each category) Assessment Areas None llitd Mild/ 1'lnderate Moderate/ Itch - High/ Comments: n_ Ntoderale. high Severe Il I 11/2 2 212 ^ 3 3-1/2 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Disruptive Behavior ❑ 0 ❑ ❑ 0 ❑ ■ Delinquent Behavior ❑ ❑ ❑ 0 0 ❑ ■ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ • . Emancipation ❑ ❑ ❑ ❑ ❑ 0 • Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ • Boundary Issues ❑ ❑ ❑•❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ • Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ■ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1 '/2 ❑ 2 ❑ 21/2 ❑ 3 ❑ 3 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT"C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE �" ;.� x;��,: '4j. �§..°„�Y'y',,r_:=,',�"r. � Sri E ydiE } I .dE6c'tiy4�:lyi di'? ?•yk`��ir`"�ay�,�ii;;u=•;�'+ y�i ! y >'ir �� i+ }t7?Ai i... � �'::s'siy-�{�z':,^�„,:-;a::,. _ NT 'ilitiv�vi 5�`t I g�{ ss2 �Z�'ui4 dd �a.�s-1, u4'�tlE[!? '..S_ �i ��'��iliE'!• } �ch iS�a �i��L�k�.f'i'rt �?. �' '�,]..il..i,.�:�•rar .'r"a ''f"ih County Basic Maintenance Rate Age 0-10...$16.32/day Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day 1 -'.•' $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 $23.01 +$,66 Respite Care ($23.67 day) 2 5*rn ' $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 $29.59 +$.66 Respite Care ($30.25 day) 3 $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4'`i" RCCF Drop Down ' $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate $29.59 +$.66 ($30.25 da Care Respite y) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this day of LOU + , 20 I 3, by and between the Board of County Commissioners of Weld County, on be alf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Roderick, Douglas and Kelli, whose address is 3110 57th Ave, Greeley CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the Countyor any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: ,0 O 2.x I. TERM: fen A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. CD e C ass B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract Revised 6/2013 a03 - ?45 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: I. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTESTA9, B Deputy Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: CWS-7A Individual Provider Contract The Board of County Commissioners of Weld County, on behalf of the Weld County Department Human Services as Rademach r, Chairman not= TRACTOR: Roderick, Douglas and Kelli 3110 57th Ave Greeley CO 80634 By: SEP 3 0 2013 ctor's (or designee's) Signature and Date 9 Revised 6/2013 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Roderick, Douglas and Kelli, hereinafter referred to as, "Contractor." GENERAL PROVISIONS County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 10994. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute. a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week O2%) 5 round trips a week O3) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required ❑2) Three times a month O3%) Three times a week or more Comments: 01) Once a month 01%) Two times month O2%) Once a week O3) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements 01) Less than a % hour per day O1%) !/z hour a day ❑2) 1 hour a day O2 '/2) 1'/z-2 hours per day O3) 2%-3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed O1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week O 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: DI) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑2) 4-8 hours per month Exhibit "B" to the Additional Provisions 5 01) Less than 4 hours per month ❑3) 9-12 hours per month Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT vior/intensity of conditions which create the need for services that apply to this child. r4 :s f Ys"' � at . ' f ....e,.f?. �. !; . x[ S' f '- `'- � �, f - '' x3°Y,. - ti ! :. It t nditrons � - ` r fS c�- ! I ! l ?n 4.Q i(C et ott�lro1 each ateg�Yl a� . f " � `. > r .... � ti yl- --". .- �, af; 'li tf 4'. L' Iv f'i 'r�. 1 i '� f 4! # i a , .- ca r' � , Assessment.`Ar'eas !, ;None '- . Mild Mild t Moderate 2 Mode -rile - High 3;1 i 1J '' . '. i Comments Moderate... iiLigh.- Z 1/2 SeKere 1 112; ,." Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ • Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ • Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ■ Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious Behavior ❑ ❑ ❑ ❑ 0 ■ ■ Substance Abuse ❑ ❑ ❑ ❑ ❑ ■ ■ Presence of Psychiatric Symptoms/Conditions � ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ 0 ❑ ❑ ❑ ❑ ❑ Runaway ❑•❑ ❑ ❑ ❑ ■ Sexual Offenses ❑ ❑ ❑ ❑ ■ ■ ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. y Y"-!'.4.--'j; t . 4 C' i`^t i 4 .N Jr '� 'a. Y! t• __a C r�i't'IS^ • 7 �� fi.� Rating of Conitio>�s�rlr�, ti a�� 71�+"fi;t n't ti 1 4§r, -Ei+� t(, b m, 1;4.-41 ,!. : 5�. �.1' ;- y"tl ri'',_Esx� (Cheek one box for each category) `" � iC it �g4 Ai vx� w r_ IL r n :L. . .. _MFnfi}`.1 ,, ,:,*". ti %' r Assessment Areas None Mild Mild, Moderate \toderattc' tilde Comments: 4 �r Moderate. ',HoltIii"h Severe 0 1 1 1 /2 2 2 1/2 3 3 1/2 Inappropriate Sexual Behavior ❑ El ❑ ❑ ■ ■ ■ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ■ ■ • Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) 0 ❑ ❑ ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ • ■ ■ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ • Boundary issues ❑ 0 0 ❑ ■ ■ ■ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ • Education ❑ ❑ ❑ ❑ ❑ ❑ • Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) El 0 ❑ 1 ❑ 1'/2 ❑ 2 ❑ 21/2 ❑ 3 ❑ 31/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 • EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE d 5v Ffi5 Si,$i � County Basic Maintenance Rate Age 0-10...$16.32/day �, ul Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day S^u� $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 u ��s $23.01 +$.66 Respite Care ($23.67 day) 2 > $26.30 +$.66 Respite Care ($26.96 day) 21/2 ' $29.59 +$.66 Respite Care ($30.25 day) 3 uyE } rq :-2:: `-x $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down iiy: $39.45 +$66 Respite Care ($40.11 day) Assessment/Emergency Rate m..i $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this ,;23 day of , 20 )3 , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Serna, Leo and Carol, whose address is 1020 Cottonwood Dr, Windsor, CO 80550, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract I Revised 6/2013 a0/ -a2Z II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional infounation when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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 C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: B Deputy 'te to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: CWS-7A Individual Provider Contract The Board of County Commissioners of Weld County, on behalf of the Weld County Department Human Services demacher, - Chairman Protein TRACTOR: SEP 3 0 2013 Serna, Leo and Carol 1020 Cottonwood Dr Windsor CO 80550 2t -Lo Cc f By: c ` jle5I(3 Director's (or designee's) Signature and Date 9 Revised 6/2013 a�c2P12,5 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Serna, Leo and Carol, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1597453. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: '10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: 01) One round trip a week ❑1%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month ❑3%:) Three times a week or more Comments: DI) Once a month ❑1'/:) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements 01) Less than a1 hour per day 011/2) '/z hour a day 02) 1 hour a day 02 %2) P/-2 hours per day 03) 2'/-3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑2) 8 to 10 hours per week O 3) Constant basis during awake hours Comments: 01) Less than 5 hours per week ❑2'/) 11 to 14 hours per week 03%) Nighttime hours ❑1/) 5 to 7 hours per week P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week ❑i%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/) 21 or more hours per week Comments: A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. O 2%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑ 3) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) Dl) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month Exhibit "B" to the Additional Provisions 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that ay to this child. :na T:..: .!_...}11 t � i i.: 4. ••••••• Y �. E tL. t f N ..., ..' - s{ ......... .. ..... ...r„,,r:r_.. ' ..: ...� t:.........(.. .. ..:... ....... ........ . t....... :: ' ..n........: ... 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F . ��?. •s li, `<'"s ! ie iGt d�. rF �x�. ✓.t':�e�i' '"!y'4•.F n�i : ^ }::::C.c to Animals ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ • ■ • Destructive of Property/Fire Setting ❑ ❑ ❑ 0 ❑ ❑ • Stealing ❑ ❑ ❑ ❑ • ■ ■ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ • Presence of Psychiatric Symptoms/Conditions 0 ❑ ❑•❑ ❑ ■ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ 0 ❑ Runaway 0 ❑ ❑ ❑ ❑ ❑• Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that annly to this child. .'.: 9 •r', ,_ ,....... --- �._.. • .: :—r:: .......!":., .. ... :.. ...- � ... ' :: ' . [7 24 ; .. :J [ : , ,::.} �. 'J gj•r.-'Y. ' ? d _h• a4'° z { ,'r+✓.4 •k { _ .r. - : •. . '..='. : _ _ . ., on box fo each o p �� .,...•; � //Check Cate Q.. � ti uu.i�.»....-E- -e:;.. i .. .. 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[ mi a• .� [., lfEr.: •':} r t r 2 �. ._ 0 11/2° 2 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ O ■ ■ Disruptive Behavior ❑ ❑ ❑ ❑ o ❑ ■ Delinquent Behavior O ❑ ❑ ❑ ■ ■ ■ Depressive -like Behavior O ❑ ■ •• ■ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ • Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ O Boundary Issues ❑ ❑ ❑ ❑ • • • Requires Night Care ❑ ❑ O ❑ ❑ ❑ ❑ Education ❑ ❑ O ❑ ❑ ❑ ■ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/2 ❑ 2 ❑ 2'/2 ❑ 3 ❑ 3'/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Age 0-10...$16.32/day ChildMaintenance/Respite County Basic Maintenance Rate 1 Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day $19.73 +$.66 Respite Care ($20.39 day) 1 112 $23.01 +$.66 Respite Care ($23.67 day) 2 $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 $29.59 +$.66 Respite Care ($30.25 day) 3 $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this 3 day of / , 20 /3 , by and between the Board of County Commissioners of Weld County, on beh if of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Sims, Mildred, whose address is 5604 Troy Villa Blvd, Dayton, OH 45424, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract I Revised 6/2013 070/9 -4 74s II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with the Needs Based Care Addendum 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 prohibiting the periodic amending of this Agreement and Addendum, in writing, if agreed to by both parties. This Agreement and Addendum are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: The Board of County Commissioners of Weld County, on behalf of the Weld County Department ATTEST e.M.o.9,of Human Services B Deputy irk to the B Approval as to Substance: WELD COUNTY DEPARTME OF HUMAN SERVICES By: CWS-7A Individual Provider Contract demach--ertl� Chairman Prote a m CTOR: s, Mildred 5604 Troy Villa Blvd Dayton, OH 45424 By: 3EP 3 0 2013 Director's (or designee's) Signatuf and Date 9 Revised 6/2013 00,6•c 5 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this &3 day of 20 /3 , by and between the Board of County Commissioners of Weld County, on be alf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Terry, Royce and Michael, whose address is 2722 Mt. Vernon, Enid, OK 73703, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from June 28, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available infoimation about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with the Needs Based Care Addendum 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 prohibiting the periodic amending of this Agreement and Addendum in writing, if agreed to by both parties. This Agreement and Addendum are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 4 0 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: s.. By: Deputy C Approval as to Substance: WELD COUNTY DEPARTME OF HUMAN SERVICES By: The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services Chairman Protem SEP 3 0 2013 , Royce and Michael 722 Mt. Vernon Enid, O 7 703 r By: C• r t Dire to 's (or ds.gnee's) Director's (or designee's) Signature S`na-ure an. D, to and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 CA70i3—O72 S INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this g day of 9tlaus r , 20 /3 , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Van Den Elzen, Dawn, whose address is 5819 W 16th St Ln, Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the tecru hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract Revised 6/2013 &&VS '45 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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 C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5.) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST ta,,odS9, B Deputy C Krk to the Approval as to Substance: WELD COUNTY DEPARTM OF HUMAN SERVICES By: CWS-7A Individual Provider Contract The Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services Cy tri l glas R/demacher, NTRACTOR: Van Den Elzen, Dawn 5819 W 16th St Ln Greeley, CO 80634 By: tit c Chairman Protein SEP3O2013 Director's (or designee's) St ature and Date 9 Revised 6/2013 020$cQ 7 , EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Van Den Elzen, Dawn, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 44282. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the telius and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A S -7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03'A) 7 round trips or more Comments: 01) One round trip a week Di 1/2) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? O Basic Maint.) No participation required ❑2) Three times a month 031/2) Three times a week or more Comments: 01) Once a month 011/2) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O Basic Maint.) No educational requirements 02) 1 hour a day ❑3%) More that 3 hours per day Comments: DI) Less than a'/3 hour per day ❑1'%) '/2 hour a day 02 %) 11/2-2 hours per day 03) 2'h-3 hours per day P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week ❑1%:) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2Y:) 11 to 14 hours per week O 3) Constant basis during awake hours ❑3/) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week ❑3'/z) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1 /) 5 to 7 hours per week ❑2%z) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. Flow often is CPA/County case management required? (Does not include therapy) OBasic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. 011/2) Face-to-face contact one time per month with child and occasional crisis intervention. ❑2) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month Exhibit "B" to the Additional Provisions 5 ❑1) Less than 4 hours per month 03) 9-12 hours per month Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. ' i � r'' 4i 1','' 4 _..i �� t j�-p' ) � i , ! .,,.,..- , .. ..,. tat>En�a {rye ,, g F K-``" 14 11� -_ r Conditions '� ' }.t`rt.F J' ,. c, � egch C � „i, eta .a roar �' r! _ kci r-�i �i.r-+'4 " t ) . _ . �' 3 f t,� M i IA' 1 c l � �}- 5 i y , �+ IL > r.. :— ...i .... u.. "...:�:.� • AssessmentAreas None .: " ! Mild Mila! - Moderate tv[Otte 'hid.' High 3 Comments Moderate. " %Ci ^ Vetere " 0 1 1 1/2 " 2 •2 1/2 ` '" _31/2.— Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ■ Verbal or Physical Threatening ❑ O ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ • Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious Behavior O ❑ ❑ ❑ O ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ • ■ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ O O ❑ ❑ O Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. p!+i44� yy _ Rat>l» of s k � t (C�CCK t) �Corrl<dit o HOC CACTI L� '!! < � �� 4 << a yk .:S Y 32 !! x z �' o-sl:Y.:$ 3�{�s � � � a _.•ki n t� s{ tl k - t r } V „i a AssessnlenfAreas None. Mild MiCd/ ` x Moderate Mod ratei High i 1 6/ n COmmentsi Moderate Hti , Si'eere 0 i 11/2 2 2=12 _ 3 Y112_" Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ O ■ Delinquent Behavior ❑ ❑ ❑ O • ■ ■ Depressive -like Behavior ❑ O ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ■ Eating Problems ❑ ❑ ❑ ❑ ■ ■ ■ Boundary Issues ❑ ❑ O ❑ ❑ ❑ • Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ O ❑ ❑ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/2 ❑ 2 ❑ 2% ❑ 3 ❑ 31/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 3 "_`'�a-y. 3 i e4 �,...se .xy-5i'* •43₹`Ro ..d_ {� °ku� r �i . ,3, +'i�E!'h.i �. ni ia��zvme County Basic Maintenance Rate Age 0-10...$16.32/day �-r Age 11-14...$18.05/day •. z Age 15-21...$19.27/day + Respite Care $.66/day 1 mmxe $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 ^'= $23.01 +$.66 Respite Care ($23.67 day) 2 • a., t $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 m! $29.59 +$.66 Respite Care ($30.25 day) 3 yt# yb $32.88 +$.66 Respite Care ($33.54day) 3 1/2 fia $36.16 +$,66 Respite Care ($36.82 day) 4 RCCF Drop Down $Y ss. - $39.45 +$.66 Respite Care ($40.11 day) „gti1 ..9 If,i ,..r $29.59 +$.66 Respite Care ($30.25 day) Assessment/Emergency Rate Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this Q day of Ni C�uS i , 2011, by and between the Board of County Commissioners of Weld County, on behhlf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Wade, Michael and Jodyne, whose address is 1016 Cottonwood Dr, Windsor, CO 80550, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract l Revised 6/2013 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Depat Unent: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement i.s nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: The Board of County Commissioners of Weld County, on behalf of the Weld County Department ATTEST:�cvsv� 9*�^� of Human Services By: Deputy r#'er to the Approval as to Substance: WELD COUNTY DEPART OF HUMAN SERVICES y Director's (or designee's re and Date, las ademacher, Chairman Protem TRACTOR: ade, Michael and Jodyne 1016 Cottonwood Dr Windsor, CO 80550 m SEP 3 0 2013 Fi .tor'(or designee's) Signature an D. e CWS-7A Individual Provider Contract 9 Revised 6/2013 c9c/s- 222>S EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Wade, Michael and Jodyne, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1554152. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. 03%) 7 round trips or more Comments: DI) One round trip a week ❑1'%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? O Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more Comments: 01) Once a month ❑1'/) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑1) Less than a''/z hour per day 011/4) 1/4 hour a day ❑2) 1 hour a day ❑2 %z) 1'/z-2 hours per day 03) 2'/z-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.) No special involvement needed 02) 8 to 10 hours per week ❑ 3) Constant basis during awake hours Comments: 01) Less than 5 hours per week ❑2%) 11 to 14 hours per week 03%) Nighttime hours O1%) 5 to 7 hours per week P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1'%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/z) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month Exhibit "B" to the Additional Provisions ❑1) Less than 4 hours per month 03) 9-12 hours per month 5 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior` intensity of conditions which create the need for services that a to this child. y 4j it,1 Ir L,Y, {GLY) ]:XI.'.YX`i `�-D�yYO4 'iSi . S�}:�•61i.t�• y[ ( y y,q5�;, `'�.."F�.;�tiFiFi z i ..:::_�} . f•�,mi -. 'aa.. Y•fig. la ,' ? 1. a inn o 1. onditions ' ,,,, Yjl�lS�.i�y °� �4 -j�wy1. _� �•: S:�:::1� �19� p yj1:C.5 ■ Yy� / F Conditions Rating &:.'h y? �-.1� . '^iF �� ! ! �1 �''�t"iL�' . 4.1At�..j YYY �_�„�� (Check one box for each cate;or )'� R e��a•� ex.- �;� 1 �` .. ^t F c:. 4 i }4t,;._ 3z �eY.i''.1�'�L4..''.t:'.E..'��' h� ;a�� 'fir<�r4��7a,t�, Assessment Areas \one N1 lid I N•tilki% Moderate %loderate/ High 1lighi Severe Coniinellts: Moderate, Ligtt 2 li2 . 0 7 1/2 2 3 3 1/2 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ • • Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ • ■ Stealing ❑ ❑ ❑ ❑ ❑ • ■ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ■ ■ Substance Abuse ❑ •❑ •❑•❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ • • Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ■ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ • ■ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED avior/intensity of conditions which create the need for services that apply to this child. •!; a _� ��: ( . . .t � atilt 1 � � - t4� i f Fti ��?'»� _ :a`.T �ti .. .: �� .e � ' , r � 3 �t �C c`k 3Pi�� 1} ce ... �.. :E ai q S - {� 15 nK�4�a�.� 3i.� is ! a. �# a. {, yy t is , iea�'h (i teg ! .a n t ,� .r_ 1 find "rt A.c v t _�� at_�F,z,,�H -w � 1i ��'i:fti- ��2 > ,(r� i "ny as ii' �h,,�x�`` u'�. ) rr t sy i � fi r ,_ i < "$i! F3r� is Assessment Areas None M3MildModerarei MiId! ,.; - . Moderate ltiloderi f ` ' ' jF��h' 3 E6� a+_ , Comm►ts �x. . Welt 2 12 Severe _ _ 0 _ 1 1 1/2.:' -2 11/2 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ■ • Depressive -like Behavior ❑ ❑ 0 ❑ ❑ ❑ ❑ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ■ ■ ■ ■ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ • Requires Night Care 0 ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ 0 ❑ ■ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: • (check level of need) ❑ 0 ❑ 1 ❑ 1'/2 ❑ 2 ❑ 2'/2 ❑ 3 ❑ 3'/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE „,rJ.��.�,�c ,..'� !;`a m?a. � x �Y fs�.r�,-.•',�w� .� �,a%�.r>�.d S�.,s��d�3 1��^.. Age 0-10...$16.32/day County Basic .fi Aye 11-14...$18.05/da Maintenance Rate n) Age 15-21...$19.27/day + Respite Care $.66/day 1« _�- $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 d (; i $23.01 +$.66 Respite Care ($23.67 day) 2 Fes: kv: S qt` sue= $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 `•si $29.59 +$.66 Respite Care ($30.25 day) ''. 3 y-sl $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down ,.s ;:� $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate a• $29.59 +$.66 Respite Care ($30.255 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this 3 day of , 20 ) 3 , by and between the Board of County Commissioners of Weld County, on alf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Willert, Melody D and Lee, Kimberly, whose address is 219 N 4th St, LaSalle, CO 80645, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 owS- II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and ka date first written above. i 0 Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES CWS-7A Individual Provider Contract COUNTY: The Board of County Commissioners of Weld County, on behalf of the Weld County Department f Human Services glas Rademacher, Chair Pro- S�� ' 2013 RACTOR: 1! 1 t1n GCS _ �I� 1D� Z Willert, Melody D an'id- Lee, Kimb 219 N 4th St LaSalle, CO 80645 By: Director's (or designee's) Signatu and Date 9 Revised 6/2013 070/S- 22 EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Willert, Melody D and Lee, Kimberly, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1540372. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th' of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A I Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit "A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week ❑1%:) 2 round trips a week O2%) 5 round trips a week O3) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? O Basic Maint.) No participation required O2) Three times a month ❑3'%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month O2%) Once a week O3) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑2) 1 hour a day O3%) More that 3 hours per day Comments: ❑1) Less than a'' /z hour per day 01%) '/2 hour a day O2 %) Ph -2 hours per day O3) 2'%-3 hours per day P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week ❑1%) 5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) II to 14 hours per week O 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1') 5 to 7 hours per week O2%) 1I to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) O2) 4-8 hours per month Exhibit "B" to the Additional Provisions 5 ❑1) Less than 4 hours per month O3) 9-12 hours per month Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions (Check one box for each category) - Assessment Areas Nom Mild ♦um! Moderate Moderatei Iliah Ijigh/ Severe... Comments: Iloderrle. high 0 1 1 1/2 2 2 1/2 3 3 1/2 Aggression/Cruelty to Animals O ❑ ❑ ❑ • • . Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑• ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ ❑ ❑ • Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ • ■ Substance Abuse ❑ ❑ ❑ • ■ • U Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ • • Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the hehavior/intensity of conditions which create the need for services that appiv to this child. Rating of Conditions ac ° zoi ",° (Cheek one box for each category) ,' ,., ' } Assessmettp has None - Mild Mild/ Moderate Moderate/ High Ili& Severe Comments: 7' Moderate. High 0 1 1. 1/2 2 2 1/2 3 3 1/2 Inappropriate Sexual Behavior 0 ❑ ❑ ❑ ❑ ❑ ■ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ 0 ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ • ■ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑•❑ O ❑ ❑ ❑ Emancipation ❑ ❑ ❑ 0 ❑ ■ ■ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ■ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ O ❑ ❑ ❑ ■ Involvement with Child's Family i ❑ 0 ❑ ❑ ❑ ■ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑I D I %2 ❑ 2 2'/2 ❑ 3 ❑ 3'/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Age 0-10...$16.32/day County Basic Maintenance Rate 1 nild Maintena Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day $19.73 +$.66 Respite Care ($20.39 day) 1 1/2 $23.01 +$.66 Respite Care ($23.67 day) 2 $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 $29.59 +$.66 Respite Care ($30.25 day) 3 $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this ,,23 day of , 20 /3 , by and between the Board of County Commissioners of Weld County, on beh f of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Wurtz, Drew and Workman-Wurtz, Katherine, whose address is 1901 15th Street, Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from July 1, 2013, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may 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; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 ao/S-a7 5 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. CWS-7A Individual Provider Contract 2 Revised 6/2013 c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. Any emergency. g. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To 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 CWS-7A Individual Provider Contract 3 Revised 6/2013 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. 23. To maintain a current license and maintain license requirements as specified under State law and rule. 24. Not to charge any fees to children or families of children referred by County for any services provided under this Agreement. 25. Not to assign the obligations under this Agreement nor enter into any sub - Agreement without the express written approval of the Director of the County Department or his/her appointed designee. 26. To maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 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. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 27. To indemnify County and the State Department 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 Agreement 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. 28. To 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 perfoimance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 III. GENERAL PROVISIONS: A. Contractor agrees that Contractor is an independent contractor and that neither Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Contractor shall have no authorization, express or implied, to bind the County to any agreement, liability, or understanding. The parties agree that Contractor will not become an employee of County, nor is Contractor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall be solely and entirely responsible for its acts or of any agent, employee, servants and sub -contractors during the performance of this Agreement. B. 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. C. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor shall be released from responsibility for loss or damage to such personal items. D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 prohibiting the periodic amending of this Agreement and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted 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 Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. 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 be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: 1. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor, or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: Deputy C The Board of County Commissioners of Weld " County, on behalf of the Weld County Department owes,_r „- of Human Services Approval as to Substance: WELD COUNTY DEPAR OF HUMAN SERVICES By: glas Radema Chairman tdni, Proem NTRACTOR: SEP 3 0 2013 urtz, Drew and Workman-Wurtz, Katherine 1901 15th Street Greeley, CO 80634 8 (IIr3By County D. or designee's) rector's (or designee's and Date 013 CWS-7A Individual Provider Contract 9 Revised 6/2013 oPVVi a7≤,� EXHIBIT "A" Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CWS-7A The following additional provisions apply to the agreement entitled, "Individual Contractor Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter referred to as, "County," and Wurtz, Drew and Workman-Wurtz, Katherine, hereinafter refelTed to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees 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 as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1633330. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4°i of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit "A" to the CWS-7A 1 Revised 6/2013 D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Contractor will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Resource Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent, in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit "A" to the CWS-7A S -7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. Attend or participate in family engagement or team decision making meetings, if requested by the Department. County staff shall notify the Contractor of the dates and times attendance is requested. 11. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the Contractor's Foster Care Coordinator. 12. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 13. 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 will be placed in the foster child's placement binder. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 18. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care Coordinator. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; C. violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Exhibit "A" to the CWS-7A 3 Revised 6/2013 D. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. E. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 22. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. Exhibit"A" to the CWS-7A 4 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: 01) One round trip a week ❑i'A) 2 round trips a week O2%) 5 round trips a week O3) 6 round trips a week P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required O2) Three times a month O3%) Three times a week or more Comments: 01) Once a month 01%) Two times month ❑2'/:) Once a week O3) Two times a week P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O Basic Maint.) No educational requirements O2) 1 hour a day ❑3%:) More that 3 hours per day Comments: _ ❑1) Less than a''/2 hour per day 01%) 'A hour a day O2 'A) 1''-2 hours per day O3) 2'A-3 hours per day P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week O1%) 5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 14 hours per week O 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week ❑ 2) 8 to 10 hours per week ❑3'%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2'A) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same Contractor. T I. How often are therapy services needed to address child's individual needs per NBC assessment? O0) Not needed or provided by another source (i.e. Medicaid) O2) 4-8 hours per month Exhibit "B" to the Additional Provisions 5 ❑1) Less than 4 hours per month ❑3) 9-12 hours per month Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behaviorintensity of conditions which create the need for services that ay to this child. _�� :... . '� r 7 iit' i '• _ 2 . ,� _ 1e'ai.''. r<Wi ` j� r ��'„r' 'z.,tt' ia- _.''fx. ��. • k .: �c� tigr.�� it" '�L. to xyT81. � ! t 7 Rating of'C Condition V {C heck one box for each category}�� H w a' e`i•Fe�,P f .� ply. • r.' =� • � 3'� �.^ �' .`'. d � $r ��R$� i. t�iu.. y S•.�, ° " �;`� 'k ,F �.''z. •_ u� '• '.�t; 4i W..°� ° .. _•'1 a. .. +i'r�73-:t=a. " Assessment Areas ._ �� gone Mild \til[I` Moderate Moderate,' IIjLh 3` tlieh: Severe Continents: ?L; 0t Moderate. - Fli th 2 12 0t'. I 2 3 1/2 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ • Verbal or Physical Threatening ❑ 0 ❑ ❑ � ❑ ❑ Destructive of Property/Fire Setting O ❑ ❑ � ❑ ❑ ■ Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ El ■ ■ Presence of Psychiatric Symptoms/Conditions ❑ ❑ � ❑ ❑ ■ ■ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ■ Runaway ❑ ❑ ❑ ❑ ❑ ❑ • Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ Exhibit "B" to the Additional Provisions 6 Revised 6/2013 EXHIBIT "B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior'intensity of conditions which create the need for services that ay to this child. Rating of Conditions (Check one box for each category) Assessment Areas None Nlild 1lsI I' Moderate Moderate( MO - High! Comments: Moderate. high Severe 0 1 1 1/2 2 2 1/2 3 U2 Inappropriate Sexual Behavior ❑ ❑ O ❑ ❑ ❑ ■ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ■ ■ Delinquent Behavior ❑ ❑ ❑ O ❑ ❑ ❑ Depressive -like Behavior ❑ ❑ ❑ O ❑ ■ ■ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ • • Emancipation ❑ ❑ ❑ O ❑ ❑ ■ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ O Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ • • Education ❑ ❑ ❑ ❑ ❑ ❑ ■ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ■ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 21/2 ❑ 3 ❑ 3'/2 Exhibit "B" to the Additional Provisions 7 Revised 6/2013 EXHIBIT "C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Age 0-10...$16.32/day County Basic Maintenance Rate 1 Age 11-14...$18.05/day Age 15-21...$19.27/day + Respite Care $.66/day $19.73 +$.66 Respite Care ($20.39 day) 1 112 $23.01 +$.66 Respite Care ($23.67 day) 2 $26.30 +$.66 Respite Care ($26.96 day) 2 1/2 $29.59 +$.66 Respite Care ($30.25 day) 3 $32.88 +$.66 Respite Care ($33.54day) 3 1/2 $36.16 +$.66 Respite Care ($36.82 day) 4 RCCF Drop Down $39.45 +$.66 Respite Care ($40.11 day) Assessment/Emergency Rate $29.59 +$.66 Respite Care ($30.25 day) Effective 7/01/2008 Exhibit "C" to the Additional Provisions 8 Revised 6/2013 Hello