HomeMy WebLinkAbout20201998.tiffAGREEMENT AMENDMENT BETWEEN
THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND AILEEN MAZAK AND COURTNEY LOWER
This Agreement Amendment, made and entered into 02/Pday of ✓�" _ 2020 by and between the Board
of Weld County Commissioners, on behalf of the Weld County Department of Human S ices, hereinafter referred to as the
"Department", and Aileen Mazak and Courtney Lower, hereinafter referred to as the "Con actor".
WHEREAS the parties entered into an Agreement for Foster Care Services, (the "Original Agreement") identified by the
Weld County Clerk to the Board of County Commissioners as document No. 2020-1998, approved on July 8, 2020.
WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the
Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms
provided herein.
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows:
• The Original Agreement will end on June 8, 2021.
• This Amendment, together with the Original Agreement, constitutes the entire understanding between the parties. The
following additional changes are hereby made to the current Agreement, effective July 1, 2020:
1. Exhibit A to the CWS-7A is hereby amended as attached.
• All other terms and conditions of the Original Agreement remain unchanged.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first
written.
above
�� COUNTY:.
ATTEST. ..0466 �(�� �"- BOARD OF COUNTY COMMISSIONERS
lerk e B • . d _ WELD COUNTY, COLORADO
By:
Deputy Clerk .'. the : , and �J � Mike Freeman, Chair
CONTRACTOR:
Aileen Aileen Mazak
Courtney Lower
90 Pike Lane
Severance, CO 80550
By: ,4/kehNam*
Aileen Mazak
Date: Jul 27, 2020
AUG 2 4 2020
By: ,our trey ».09.<,.1,
Courtney Lower
Date: Aug 8, 2020
c 6. ()A,43,„„m,6-4--0
2020-1G1 q8
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility
Agreement CWS-7A
The following additional provisions in this Exhibit A, and Addendum 1 and Addendum 2, apply to the
agreement entitled, "Individual Provider Contract for Purpose of Foster Care Services and Foster Care
Facility Agreement," by and between the Weld County Department of Human Services, hereinafter referred
to as, "County," and Mazak, Aileen and Lower, Courtney, hereinafter referred to as, "Provider."
GENERAL PROVISIONS
1. 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. This provision does not affect removal of a child in an emergency
situation.
2. Provider agrees that Provider is an independent contractor and that neither Provider nor Provider's agents
or employees are, or shall be deemed to be, agents or employees of the County for any purpose. Provider
shall have no authorization, express or implied, to bind the County to any agreement, liability, or
understanding. The parties agree that Provider will not become an employee of County. Provider shall be
solely and entirely responsible for its acts or of any agent, employee, servants and sub -Providers during the
performance of this Agreement. Provider is not entitled to unemployment insurance or workers'
compensation benefits through Weld County and Weld County shall not pay for or otherwise
provide such coverage for Provider. Unemployment insurance benefits will not be available to
Provider for services provided under this Agreement. Provider shall pay when due any/all applicable
employment taxes and income taxes and local head taxes (if applicable) incurred as a result of the
services provided under this Agreement.
3. 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.
4. This Exhibit A is intended to be applied in conjunction with the attached Agreement 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 in writing, if agreed to by both parties. The Agreement, this Exhibit A
and the rate Addendums are intended to be in lieu of and supersede all prior agreements between the
parties hereto and relating to the care and services herein described.
5. The State of Colorado Department of Human Services and the County shall be and hereby is permitted to
monitor the 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 child or youth. Monitoring may occur
through review of program reports, on -site visits where applicable and other Agreements as deemed
necessary. Provider understands that the State Department and the County may provide consultation to
Provider to assure satisfactory performance in the provision of purchased services under thisAgreement.
6. County shall have access to Provider's service program, financial and other records, which will sufficiently
and properly reflect all direct and indirect costs of any nature incurred in the performance of 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.
7. Time is of the essence in each and all of the provisions of this Agreement.
Exhibit A to the CWS-7A
1 Revised 6/2020
8. 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.
9. 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 in thisAgreement.
10. This Agreement is nonexclusive and County may engage or use other Providers or persons to perform
services of the same or similar nature.
11. Provider certifies, warrants, and agrees that it does not knowingly employ or contract with an illegal alien
who will perform work under this contract. Provider will confirm the employment eligibility of all employees
who are newly hired for employment in the United States to perform work under this Agreement, through
participation in the E -Verify program or the State of Colorado program established pursuant to C.R.S. §8-
17.5-102(5)(c). Provider shall not knowingly employ or contract with an illegal alien to perform work under
this Agreement or enter into a contract with a sub -contractor that fails to certify with Provider that the sub-
contractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement.
Provider shall not use E -Verify Program or State of Colorado program procedures to undertake pre-
employment screening or job applicants while this Agreement is being performed. If Provider obtains actual
knowledge that a sub -contractor performing work under the public contract for services knowingly employs
or contracts with an illegal alien Provider shall notify the sub -contractor and County within three (3) days
that Provider has actual knowledge that a sub -contractor is employing or contracting with an illegal alien and
shall terminate the subcontract if a sub -contractor does not stop employing or contracting with the illegal
alien within three (3) days of receiving notice. Provider shall not terminate the contract if within three days
the sub -contractor provides information to establish that the sub -contractor has not knowingly employed or
contracted with an illegal alien. Provider shall comply with reasonable requests made in the course of an
investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the Colorado Department of Labor and
Employment. If Provider participates in the State of Colorado program, Contract Professional shall, within
twenty days after hiring a new employee to perform work under the contract, affirm that Provider has
examined the legal work status of such employee, retained file copies of the documents, and not altered or
falsified the identification documents for such employees. Provider shall deliver to County, a written
notarized affirmation that it has examined the legal work status of such employee, and shall comply with all
of the other requirements of the State of Colorado program. If Provider fails to comply with any requirement
of this provision or of C.R.S. §8-17.5-101 et seq., County, may terminate this Agreement for breach, and if
so terminated, Provider shall be liable for actual and consequential damages.
Except where exempted by federal law and except as provided in C.R.S. § 24-76.5 103(3), if Provider
receives federal or state funds under the contract, Provider must confirm that any individual natural person
eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. § 24-76.5-
103(4), if such individual applies for public benefits provided under the contract. If Provider operates as a
sole proprietor, it hereby swears or affirms under penalty of perjury that it: (a) is a citizen of the United
States or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of
the forms of identification required by C.R.S. § 24-76.5-101, et seq., and (c) shall produce one of the forms
of identification required by C.R.S. § 24-76.5-103 prior to the effective date of the contract.
12. Provider assures and certifies 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;
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;
C. 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.
Exhibit A to the CWS-7A
2 Revised 6/2020
D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal,
state, and local) terminated for cause ordefault.
13. In addition to terminating this Agreement in accordance with the provisions herein, County may exercise the
following remedial actions if the County finds and determines that the Provider has substantially failed to
satisfy the duties found in this Agreement and Exhibit A Substantial failure to satisfy the scope of work shall
be defined to mean incorrect or improper activities or inaction by the Provider. These remedial actions
include, but are not limited to, any one or more of the following:
A. Withhold payment to Provider 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 Provider 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.
C. Recover from Provider any incorrect payment to Provider due to omission, error, fraud, and/or defalcation
by deducting from subsequent payments under this Agreement, or other agreements between County and
Provider, or as a debt to County, or otherwise as provided by law.
14. 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.
15. 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 deemedto 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.
16. Provider 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 Provider, 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.
17. This Agreement and the provision of services hereunder shall be subject to the laws ofColorado and be in
accordance with the policies, procedures, and practices of County. Provider shall strictly comply with all
applicable federal and State laws, rules and regulations in effect or hereafter established.
18. Financial obligations of the County payable after the current fiscal year are contingent upon funds for that
purpose being appropriated, budgeted and otherwise made available. Execution of this Agreement by
County does not create an obligation on the part of County to expend funds not otherwise appropriated in
each succeeding year.
19. County and Provider agree that the State approved base rate shall be used for the Child Maintenance rate
for any child age birth to 12 unless the child has severe behavioral challenges and is receiving intensive
services and the Child Welfare Director or designee approves use of the Child and Adolescent Needs and
Strengths assessment to determine the rate as specified in the Addendum 1. For any child age 13 or older,
the Child and Adolescent Needs and Strengths assessment will automatically be completed to determine
the rate as specified in the Addendum. If the child, regardless of age, has Intellectual or Developmental
Disabilities or intensive medical/physical needs or limitations that interfere with daily life functioning, the
Inventory for Client and Agency Planning (ICAP) assessment will be completed to determine the
reimbursement rate as specified in Addendum 2.
20. County agrees to purchase, and Provider agrees to provide the care and services, which are listed in this
Agreement. The State approved rate of payment will be paid for the Child Maintenance level of service,
Exhibit A to the CWS-7A 3 Revised 6/2020
unless the Child and Adolescent Needs and Strengths or the Inventory for Client and Agency Planning
assessment has been completed and the rate determined as designated in Addendum 1 or Addendum 2
respectively, for children placed within the Weld County Certified Foster Care Home identified as
Provider ID# 1743387. 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.
21. All bed hold authorizations and payments are subject to a 7 -day maximum for a child's temporary absence
from a facility; however, if the absence is a result of hospitalization the maximum bed hold authorization
may be up to 14 days. Bed hold requests must have prior written authorization from the Department
Administrator or Designee before payment will be release to Provider.
22. 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.
23. 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 ofthe 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.
D. Transportation reimbursement shall be for visitation purposes or transportation to school if out of county and
with prior approval only If medical transportation is needed, Provider will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the
Resource Manager or the DepartmentAdministrator.
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).
24. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal
items brought to Provider by the children, Provider shall be released from responsibility for loss or damage to
such personal items.
PROVIDER SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the
Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any
applicable federal laws and regulations, as such, which may be amended from time to time, and shall be
binding on Provider and control any disputes in this Agreement.
2. Not charge any fees to children or families of children referred by County for any services provided under
this Agreement.
3. Not 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.
4. Maintain at all times during the term of this Agreement a liability insurance policy of atleast
$25,000 for property damage liability, $150,000 for injury and/or damage to any one person, and
$500,000 for total injuries arising from any one accident. Provider shall provide a certificate of insurance
provided by its insurer upon request by County.
5. Indemnify the County 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
Exhibit A to the CWS-7A
4 Revised 6/2020
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.
6. Attend or participate in Ice Breaker, Family Engagement or Team Decision making meetings, if requested by
the Department. County staff shall notify the Provider of the dates and times attendance is requested.
7. 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 Provider's Foster Care Coordinator.
8. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by the
Weld County Department of Human Services to preserve placement in the least restrictive placement
appropriate, comply with the treatment plan of the child, and attendcourt hearings as requested.
9. Have physical examinations completed within 14 days and dental examinations completed within 8 weeks of
the child being placed with Provider. All documentation of these examinations will be placed in the foster
child's placement binder.
10. Attend all necessary school meetings and support any plan that is developed regarding the child in order to
promote educational success.
11. 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.
12. Maintain, access and review information weekly on FIDOS.
13. Maintain/update information in the foster child's binder. The binder will be reviewed on amonthly basis and
signed off by child's caseworker and/or the Provider's Foster Care Coordinator.
14. Maintain/update medication logs on a daily basis, if child is taking medications.
15. 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
5 Revised 6/2020
ADDENDUM 1
Child and Adolescent Needs and Strengths (CANS) Rates
Level of Service
CANS Score
Child Maintenance
Daily Rate
0 and 1
$35.70
2
$42.28
3
$48.86
ADDENDUM 2
Inventory for Client and Agency Planning (ICAP) Rates
ICAP IDD Level
Child Maintenance
Daily Rate
Level 1
$97.11
Level 2
$112.64
Level 3
$123.75
Level 4
$134.86
Level 5
$154.94
Level 6
$194.75
Medically Fragile
Level 1
$54.73
Level 2
$110.30
Level 3
$165.88
Level 4
Negotiate up to $200
Contract Form
New Contract Request
Entity Information
Entity Name*
MAZAK, AILEEN
Entity 1D't
@00042390
Contract Name*
MAZAK, AILEEN AND LOWER COURTNEY (AGREEMENT
AMENDMENT)
Contract Status
CTB REVIEW
❑ New Entity?
Contract ID
4022
Contract Lead
CULLINTA
Contract Lead Email
r_ullinta@co weld co us;cobbxxl
k@co weld.co.us
Contract Description *
AMENDMENT OF EXISTING PLACEMENT CONTRACT TO UDPATE EXHIBIT A.
Contract Description 2
Contract Type*
AGREEMENT
Amount*
$0.00
Renewable*
NO
Automatic Renewal
Grant
IGA
Department
HUMAN SERVICES
Department Email
CM-
HumanServices@weldgov corn
Department Head Email
CM-HurnanServices-
DeptHead@weldgov.com
County Attorney
GENERAL COUNTY
ATTORNEY EMAIL
County Attorney Email
CM-
COUNTYATTORNEY@WELD
GOV. COM
Requested I3OCC Agenda
Date*
08/26/2020
Parent Contract ID
20201998
Requires Board Approval
YES
Department Project #
Due Date
08/22/2020
Will a work session with BOCC be required?*
NO
Does Contract require Purchasing Dept. to be included?
If this is a renewal enter previous Contract ID
If this is part of a MSA enter MSA Contract ID
Note the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in
OnBase
Contract Dates
Effective Date
Termination Notice Period
Review Date*
04`08/2021
Renewal Date
Committed Delivery Date Expiration Date*
0610&2021
Contact Information
Contact Info
Contact Name
Purchasing
Purchasing Approver
Approval Process
Department Head
JAMIE ULRICH
DH Approved Date
08/19/2020
Final Approval
BOCC Approved
BOCC Signed Date
BOCC Agenda Date
08/24/2020
Originator
CULLINTA
Contact Type Contact Email
Finance Approver
CHRIS D'OVIDIO
Contact Phone 1 Contact Phone 2
Purchasing Approved Date
Finance Approved Date
08/19/2020
Tyler Ref #
AG 082420
Legal Counsel
GABE KALOUSEK
Legal Counsel Approved Date
08/19/2020
Submit
RESOLUTION
RE: APPROVE INDIVIDUAL PROVIDER CONTRACT FOR PURCHASE OF FOSTER CARE
SERVICES IN A FOSTER CARE HOME AND AUTHORIZE CHAIR TO SIGN -
AILEEN MAZAK AND COURTNEY LOWER
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with an Individual Provider Contract for
Purchase of Foster Care Services in a Foster Care Home between the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Human Services, and Aileen Mazak and Courtney Lower, commencing June 9,
2020, and ending June 8, 2021, with further terms and conditions being as stated in said contract,
and
WHEREAS, after review, the Board deems it advisable to approve said contract, a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the Individual Provider Contract for Purchase of Foster Care
Services in a Foster Care Home between the County of Weld, State of Colorado, by and through
the Board of County Commissioners of Weld County, on behalf of the Department of Human
Services, and Aileen Mazak and Courtney Lower, be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said contract.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 8th day of July, A.D., 2020, nunc pro tunc June 9, 2020.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: dith,„„ �' •XLto•6k.
Weld County Clerk to the Board
Deputy Clerk to the
ounty Attorney
Date of signature: 0743 /ao
Mike Freeman, Chair
Steve Moreno, Pro-Tem
Gc;HSD
°7/31 /20
2020-1998
HR0092
c.1-'rlot.-f D 3V.
LIAL
MEMORANDUM
DATE: June 23, 2020
TO: Board of County Commissioners — Pass -Around
FR: Jamie Ulrich, Director, Human Services
RE: Various Individual Provider Contracts for Foster Care
Services
Please review and indicate if you would like a work session prior to placing this item on the Board's agenda.
Request Board Approval of the Department's Various Individual Provider Contracts for the
Purpose of Foster Care Services. The major provisions of these contracts are:
CMS ID
Provider/Term
Facility
Type/Location
Daily Rate
3722
Scudder, Nathan and Mistie
(RECERTIFICATION/
CONSENT: 2019-4495)
06/30/2020-06/02/202 I
County Foster Care
Eaton, CO
Negotiated on needs of
child(ren)
3723
Cross, Taylor and Hannah
(NEW FOSTER)
06/04/2020-06/03/2021
County Foster Care
LaSalle, CO
Negotiated on needs of
child(ren)
3724
Lozen, Jon and Teri
(NEW FOSTER)
06/08/2020-06/07/202 I
County Foster Care
Windsor, CO
Negotiated on needs of
child(ren)
3725
Mazak, Aileen and Lower, Courtney
(NEW FOSTER)
06/09/2020-06/08/202 1
County Foster Care
Severance, CO
Negotiated on needs of
child(ren)
3726
Porras-Valencia, Feliciano and Pulido,
La Tasha
(NEW KINSHIP)
County Foster Care
Greeley, CO
Negotiated on needs of
child(ren)
Pass -Around Memorandum; June 23, 2020 - CMS Various
2020-1998
O1O8
PRIVILEGED ANI) CONFIDENTIAL
I do not recommend a Work Session. I recommend approval of these Contracts and authorize the Chair to
sign.
Approve Schedule Other/Comments:
Recommendation Work Session
Mike Freeman, Chair
Scott James
Barbara Kirkmeyer
Steve Moreno, Pro -Tern
Kevin Ross
Pass -Around Memorandum; June 23, 2020 -- CMS Various
Page 2
COLORADO
Office of Children,
Youth & Families
INDIVIDUAL PROVIDER CONTRACT
FOR PURCHASE OF FOSTER CARE SERVICES IN A FOSTER CARE HOME
1. THIS CONTRACT AND AGREEMENT, made this date,
Department of Human Services, P. O. Box A, Greeley,
and Mazak, Aileen and Lower, Courtney, 90 Pike L:ne,
"Provider".
o by and between the Weld County
2, hereinafter called "County Department"
verance, CO 80550, hereinafter called
2. This Contract and Agreement shall be effective from 6-1 , 2020 and continue in force until 6 - $ , 2021 or
until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time
during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior
purchase contracts between the parties hereto and relating to the services herein described.
3. The Provider holds a valid certificateas a Foster Care home. Such certification standards shall be maintained
during the term hereof. The provider has read and is fully familiar with the "Rules Regulating Foster Care
Homes" issued by the Colorado Department of Human Services.
4. The County Department may but shall not be obligated to purchase foster care home services. The County
Department or any duly authorized agent may request such services to be provided to any child or youth at any
time within the limits of the certificate and without prior notice. At such time or as soon as possible after the
acceptance of a child or youth for services, the County Department and the Provider shall verify foster care
placement of each child or youth in writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
5. The terms of this Agreement are contained in the terms recited in this document and in Exhibit A and Addendum 1
and 2, which form integral parts of this Agreement. Exhibit A and Addendum 1 and 2 are specifically incorporated
herein by this reference.
The Provider agrees:
1. To furnish foster care services to eligible children and youth at the established rate based on the individual
child or youth rates negotiated between the county department and the provider;
2. To safely provide the 24 -hour physical care and supervision of each child or youth until removed or
until the agreement is renewed;
3. To accept a child or youth, only with the approval of the certifying agency;
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans -for a child or youth in placement, including visits with their
parents, siblings, relatives, or to transition to another foster care facility;
5. To maintain approved standards of care as set by the Colorado Department of Human Services;
6. To maintain the confidentiality of information shared about the child or youth and his/her family;
7. Not to accept money from parents or guardians;
8. Not to make any independent agreement with parents or guardians;
1575 Sherman Street, 2nd Floor, Denver, CD 30203 P 303-366-5932 F 303-866-5536 www.colorado.gov/cdhs
John W. dickenlooper, Governor Reggie 61c'ha; Executive Director
O�O� - / 991
9. Not to release the child or youth to anyone without prior authorization from the County Department;
10. To allow representatives of the County Department to visit the foster care home and to meet with the
child or youth at any reasonable time, including scheduled and unscheduled visits; and,
11. To give the County Department a 30 -day notice, except in an emergency, to remove a child or youth
for placement elsewhere, and to work with the County Department as requested to prepare the child or
youth for another placement.
12. To provide transportation to the child or youth. 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 Service Plan. Transportation must be provided or
arranged:
a. For professional services and/or for school attendance when necessary; and,
b. For children or youth to participate in age or developmentally appropriate extracurricular, enrichment,
cultural, and social activities.
13. To report promptly to the County Department:
a. Any unplanned absence of the child or youth from provider's care;
b. Any major illness of the child or youth;
c. Any serious injury to the child or youth;
d. Any significant change in the sleeping arrangement for the child or youth;
e. Any contemplated change of address or change of household members;
f. Any conflict the child or youth may have with law enforcement, school/school district staff, or other persons
in authority;
g. Any emergency;
h. Any pertinent discussion with parents or guardians about the child or youth or supervising agency; and,
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, sexual orientation, expression, or identity, religion, political beliefs,
national origin, or handicapping condition.
15. To complete pre -service training prior to the placement of a child or youth.
16. To annually:
a. Update the Training Development Plan with the County Department;
b. Complete ongoing, quality, and relevant training that will build competencies to meet the needs of the
children and youth served in the foster care home as required by the Colorado Department of Human
Services regulations; and,
c. Obtain certification to use and apply the reasonable and prudent parent standard for each child or youth served
in the foster care home.
17. To attend semi-annual Administrative Reviews for a child or youth in placement.
18. To be knowledgeable of, and comply with the "Rules Regulating Foster Care Homes" and the "General Rules for
Child Care Facilities;
19. Not to enter into any subordinate subcontract hereunder;
20. To keep required and necessary records for audit/review purposes by state and federal personnel. These records
shall document the type of care and dates that care is provided for each child or youth. In addition, medical,
educational, and progress summary records shall be maintained for each child or youth as required pursuant to the
Colorado Department of Human Services' Rules Regulating Family Foster Care Homes.
21. To complete or schedule a medical examination for the child or youth within 14 days after initial placement and a
dental examination within eight weeks of initial placement;
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303.866-5932 F 303-866-5536 www.colorado.gov/cdhs
kiln W. Hickenlooper, Governor i Reggie Bicha, Executive Director
2
The County Department agrees:
1. To share all available information about the child or youth, including relevant social, medical and educational history,
behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics
of the child or youth, with the provider before placement and to share additional information when obtained while
the child or youth is in placement.
2. To inform the provider of expectations regarding the care of the child or youth, such as meeting medical needs,
visitation, special psychological needs, trauma and other grief/loss issues, and the child's or youth's identification with
his/her family;
3. To give the provider the written admission record of the child or youth to the foster care home at the time of placement;
4. To give the provider a written procedure or authorization for obtaining medical care for the child or youth;
5. To involve the provider in family service planning for the child or youth as a member of treatment team;
6. To give the provider a copy of the Family Service Plan, as it pertains to their expectations for meeting the needs of the
child or youth in the foster care home, at the time of placement or when it is completed following placement;
7. To give at least a 30 -day notice of plans to remove a child or youth from the foster care home. The 30 -day notice may
be waived by mutual consent to allow and permit immediate removal of a child or youth 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 a child or youth.
8. To pay the provider at the rates established by the Colorado Department of Human Services or as authorized and
negotiated between the provider and the County Department:
a. Payment shall be made by electronic banking transfers (EBT) drawn by the duly authorized county officer; and,
b. Provider shall notify the County Department of any payment or billing dispute within 60 days of the month
when service was provided. Failure to do so will result in forfeiture of the payment. The Provider understands
that, pursuant to the Colorado Department of Human Services' Rules for the General Reimbursement for Child
Welfare Services, when reimbursement is warranted current and (2) preceding months.
9. To provide or arrange through statewide contracted training, a minimum of twelve hours of core pre -service
training for foster care homes and 15 hours of pre -service training directed at the needs of the child or youth to be
served in the foster care home.
10. To annually complete the following:
a. Update the Training Development Plan with the provider;
b. Provide or make available quality and relevant training for each foster parent that will build competencies to
meet the needs of the children and youth served in the foster care home;
c. Provide training that prepares each foster parent to use and apply the reasonable and prudent parent
standard; and,
d. Pursuant to the Colorado Department of Human Services' Rules Regulating Family Foster Care Homes,
document that the provider is trained in, and can use and apply the reasonable and prudent parent standard
for each child or youth placed in the foster care home.
11. The County Department is responsible for providing information on county specific procedures.
12. To invite the provider to Administrative Reviews for each child or youth in placement.
1575 Snerrnan Street. 2nd Floor. Denver, CO 80203 P 303-866-5932 F 303-806-5536 www.col.orado.goviodhs
John W. Hickenlooper, Governor I Reggie Bicha, Executive Director
3
13. To incorporate provider information in planning for the child or youth placed in the foster care home.
14. To assure that the service described herein has been accomplished and a record made thereof on a case by case
basis.
15. To provide notice of court hearings for each child or youth placed in the foster care home.
State of Colorado
Weld County Government
County Department (type or print)
7a/rieUG/7h
Jamie Ulrich (Jun 23, 202013:42 MDT)
Jun 23, 2020
Signature
Date
WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first writtenabove.
COUNTY:
ATTES
Weld
By:
Deputy
PROVIDER:
Aileen Mazak
Signature
Provider (type or print)
Courtney Lower
ARD OF COUNTY COMMISSIONERS
LD COUNTY, COLORADO
Freeman, Chair
Provider (type or print)
Signature
JUL 0 8 2020
G -mod O
Date
Date
lY' 4-(Jjr
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303-866-5536 www.colorado.gov/cdhs
John W. Hickenlooper, Governor I Reggie Bicha, Executive Director
4
Y
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions in this Exhibit A, and Addendum 1 and Addendum 2, apply to the
agreement entitled, "Individual Provider Contract for Purpose of Foster Care Services and Foster Care
Facility Agreement," by and between the Weld County Department of Human Services, hereinafter
referred to as, "County," and Cross, Taylor and Cross, Hannah, hereinafter referred to as, "Provider."
GENERAL PROVISIONS
1. 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. This provision does not affect removal of a child in an emergencysituation.
2. Provider agrees that Provider is an independent contractor and that neither Provider nor
Provider's agents or employees are, or shall be deemed to be, agents or employees of the
County for any purpose. Provider shall have no authorization, express or implied, to bind the
County to any agreement, liability, or understanding. The parties agree that Provider will not
become an employee of County, nor is Provider entitled to any employee benefits from County as
a result of the execution of this Agreement. Provider shall be solely and entirely responsible for
its acts or of any agent, employee, servants and sub -Providers during the performance of this
Agreement.
3. 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.
4. This Amendment is intended to be applied in conjunction with attached Agreement and the Needs
Based Care Addendum as the complete integration of all understandings between theparties.
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 or the Needs Based Care Addendum in writing, if agreed to by both
parties. The Agreement, this Exhibit A and the Needs Based Care Addendum are intended to be
in lieu of and supersede all prior agreements between the parties hereto and relating to the care
and services herein described.
5. The State of Colorado Department of Human Services and the County shall be and hereby is
permitted to monitor the 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 child
or youth. Monitoring may occur through review of program reports, on -site visits where
applicable and other Agreements as deemed necessary. Provider understands that the State
Department and the County may provide consultation to Provider to assure satisfactory
performance in the provision of purchased services under thisAgreement.
6. County shall have access to Provider's service program, financial and other records, which will
sufficiently and properly reflect all direct and indirect costs of any nature incurred in the
performance of 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 paymenthereunder.
7 Time is of the essence in each and all of the provisions of this Agreement.
Exhibit A to the CWS-7A
5 Revised 6/2019
8. 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.
9. 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 in thisAgreement.
10. This Agreement is nonexclusive and County may engage or use other Providers or persons to
perform services of the same or similar nature.
11. Provider certifies, warrants, and agrees that it does not knowingly employ or contract with an
illegal alien who will perform work under this contract. Provider will confirm the employment
eligibility of all employees who are newly hired for employment in the United States to perform
work under this Agreement, through participation in the E -Verify program or the State of Colorado
program established pursuant to C.R.S. §8-17.5-102(5)(c). Provider shall not knowingly employ
or contract with an illegal alien to perform work under this Agreement or enter into a contract with
a sub -contractor that fails to certify with Provider that the sub -contractor shall not knowingly
employ or contract with an illegal alien to perform work under this Agreement. Provider shall not
use E -Verify Program or State of Colorado program procedures to undertake pre -employment
screening or job applicants while this Agreement is being performed. If Provider obtains actual
knowledge that a sub -contractor performing work under the public contract for services knowingly
employs or contracts with an illegal alien Provider shall notify the sub -contractor and County
within three (3) days that Provider has actual knowledge that a sub -contractor is employing or
contracting with an illegal alien and shall terminate the subcontract if a sub -contractor does not
stop employing or contracting with the illegal alien within three (3) days of receiving notice.
Provider shall not terminate the contract if within three days the sub -contractor provides
information to establish that the sub -contractor has not knowingly employed or contracted with an
illegal alien. Provider shall comply with reasonable requests made in the course of an
investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the Colorado Department of
Labor and Employment. If Provider participates in the State of Colorado program, Contract
Professional shall, within twenty days after hiring a new employee to perform work under the
contract, affirm that Provider has examined the legal work status of such employee, retained file
copies of the documents, and not altered or falsified the identification documents for such
employees. Provider shall deliver to County, a written notarized affirmation that it has examined
the legal work status of such employee, and shall comply with all of the other requirements of the
State of Colorado program. If Provider fails to comply with any requirement of this provision or of
C.R.S. §8-17.5-101 et seq., County, may terminate this Agreement for breach, and if so
terminated, Provider shall be liable for actual and consequential damages.
Except where exempted by federal law and except as provided in C.R.S. § 24-76.5 103(3), if
Provider receives federal or state funds under the contract, Provider must confirm that any
individual natural person eighteen (18) years of age or older is lawfully present in the United
States pursuant to C.R.S. § 24-76.5-103(4), if such individual applies for public benefits provided
under the contract. If Provider operates as a sole proprietor, it hereby swears or affirms under
penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully present in the
United States pursuant to federal law, (b) shall produce one of the forms of identification required
by C.R.S. § 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required
by C.R.S. § 24-76.5-103 prior to the effective date of the contract.
12. Provider assures and certifies 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.
Exhibit A to the CWS-7A
6 Revised 6/2019
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; 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;
C. 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.
D. Have not within a three-year period preceding this Agreement, had one or more public
transactions (federal, state, and local) terminated for cause ordefault.
13. In addition to terminating this Agreement in accordance with the provisions herein, County
may exercise the following remedial actions if the County finds and determines that the
Provider has substantially failed to satisfy the duties found in this Agreement, Exhibit A or the
Needs Based Care Addendum. Substantial failure to satisfy the scope of work shall be defined
to mean incorrect or improper activities or inaction by the Provider. These remedial actions
include, but are not limited to, any one or more of the following:
A. Withhold payment to Provider 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 Provider 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.
C. Recover from Provider any incorrect payment to Provider due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under thisAgreement, or
other agreements between County and Provider, or as a debt to County, or otherwise as
provided by law.
14. 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.
15. 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 deemedto
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.
16. Provider 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 Provider, 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.
17. This Agreement and the provision of services hereunder shall be subject to the laws ofColorado
and be in accordance with the policies, procedures, and practices of County. Provider shall
strictly comply with all applicable federal and State laws, rules and regulations in effect or
hereafter established.
18. Financial obligations of the County payable after the current fiscal year are contingent upon funds
Exhibit A to the CWS-7A 7 Revised 6/2019
for that purpose being appropriated, budgeted and otherwise made available. Execution of this
Agreement by County does not create an obligation on the part of County to expend funds not
otherwise appropriated in each succeeding year.
19. County and Provider agree that a child specific Needs Based Care Assessment, designated as
Addendum 1 shall be used to determine the Child Maintenance and Medical Needs, if applicable,
for each child placed with Provider unless otherwise negotiated and approved by the County.
20. County agrees to purchase and Provider 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 the Child Maintenance level of service, as indicated by the Needs
Based Care Rate Table, designated as Addendum 2, for children placed within the Weld County
Certified Foster Care Home identified as Provider ID# 1743387. 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.
21. All bed hold authorizations and payments are subject to a 7 -day maximum for a child's temporary
absence from a facility; however, if the absence is a result of hospitalization the maximum bed
hold authorization may be up to 14 days. Bed hold requests must have prior written authorization
from the Department Administrator or Designee before payment will be release to Provider.
22. 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.
23. 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 ofthe month following
service, it may result in forfeiture ofpayment.
C. Placement service reimbursement shall be paid from the date of placement up to, but not
including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Provider 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).
24. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and
protect personal items brought to Provider by the children, Provider shall be released from
responsibility for loss or damage to such personal items.
PROVIDER SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of Human
Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State
of Colorado and any applicable federal laws and regulations, as such, which may be amended
from time to time, and shall be binding on Provider and control any disputes in this Agreement.
2. Not charge any fees to children or families of children referred by County for any services
provided under this Agreement.
Exhibit A to the CWS-7A
8 Revised 6/2019
3. Not 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.
4. Maintain at all times during the term of this Agreement a liability insurance policy of atleast
$25,000 for property damage liability, $150,000 for injury and/or damage to any one person, and
$500,000 for total injuries arising from any one accident. Provider shall provide a certificate of
insurance provided by its insurer upon request by County.
5. Indemnify the County 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.
6. Attend or participate in ice Breaker, Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Provider of the dates and times
attendance is requested.
7 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 Provider's Foster Care
Coordinator.
8. Actively participate in achieving the child's permanency goal, cooperate with any contractors
hired by the Weld County Department of Human Services to preserve placement in the least
restrictive placement appropriate, comply with the treatment plan of the child, and attendcourt
hearings as requested.
9. Have physical examinations completed within 14 days and dental examinations completedwithin
8 weeks of the child being placed with Provider. All documentation of these examinations will be
placed in the foster child's placement binder.
10. Attend all necessary school meetings and support any plan that is developed regarding the child
in order to promote educational success.
11. 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.
12. Maintain, access and review information weekly on FIDOS.
13. Maintain/update information in the foster child's binder. The binder will be reviewed on amonthly
basis and signed off by child's caseworker and/or the Provider's Foster Care Coordinator.
14. Maintain/update medication logs on a daily basis, if child is taking medications.
15. Maintain behavior observation notes as required by the level of care assessed for each child.
16. 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
9 Revised 6/2019
ADDENDUM 1
Needs Based Care Assessment
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7) questions are mutually exclusive.
P1. How often does the child require transportation by the foster care provider for the
following:
Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as
outlined in the treatment plan?
Select One
P2. How often is the foster care provider required to participate in child's therapy or
counseling sessions?
P3. How much time is the provider required to intervene at home and/or at school with the
child in conjunction with a regular or special education plan?
Select One
Select One
P4. How often does the child require special and extensive involvement by the provider in
scheduling and monitoring of time and/or activities and/or crisis management?
Select One
P5. How much time is the provider required to assist the child because of impairments
beyond age appropriate needs with feeding, bathing, grooming, physical, and/or
occupational therapy?
Select One
Al. How often is CPA/County case management required? (Does not include therapy)
**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 provider.
Select One
T1. How often are therapy services needed to address child's individual needs per NBC
assessment?
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Select One
r
O
C
Assessment Areas:
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
Inappropriate Sexual Behavior
Disruptive Behavior
Delinquent Behavior
Depressive -like Behavior
Medical Needs - (If condition is rated "severe",
please complete the Medically fragile NBC)
Emancipation
Comment:
Rating:
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Eating Problems
Select One
Boundary Issues
Select One
Requires Night Care
Select One
Education
elect One
Involvement with Child's Family
Select One
Addendum 1
10
Revised 5/2018
ADDENDUM 2
Needs Based Care Rate Table
Weld County Department of Human Services
(Effective 7/01/2018)
CIII
1)0il;, Ralf:
1).11. t
County
Basic
Maintenance
Rate
$35.70
$.66
l
$35.70
:$.66
63.54
1 '/
$35.70
$.66
2
$35.70
$.66
$5.09
2'/a
$38.99
$,66
3
$42.28
$,66
$6.66
3 1/2
$45.57
$.66
----- --
4
Congregate
Care
Drop Down
$48.86
6.66
Negotiated
Assessment/
Emergency
Level Rate
$35.70
$.66
Addendum 2
11
Revised 8/2018
New Conte ►ct Refines
Entity informatuall
cne
dLEEN
Contract Name*
M , AILEEN AND LOWER, COURTNEY
Contract Status
CTB REVIEW
Entity ID*
@00042390
Contract Description*
CWS-7A (NEW FOSTER). TERM. 06109/20-06/08/21
Contract Description 2
Contract Type
CONTRACT
Amount
50.00
Renewable*
NO
Automatic Renewal
ICA
Department
HUMAN SERVICES
Department Email
CM-
HumanServices@weidgovcom
Department Head Email
CM-HumanServices-
DeptHead Idgov.corn
County Attorney
GENERAL COUNTY
A I I ORNEY EMAIL
County Attorney Email
CM-
COUNTYAIIORNEY@WELD
GOV. COM
❑ New Entity?
Contract ID
3725
Contract Lead*
CULLINTA
Contract Lead Email
cullinta@co.weld.co.us;cobbxxl
kgico.weld.co.us
co. us
Requested BOCC Agenda
Date*
06/24/2020
Parent Contract ID
Requires Board Approval
YES
Department Project #
Due Date
06/20/2020
Will a work session with BOCC be required?
NO
Does Contract require Purchasing Dept. to be included?
If this is a renewal enter previous Contract ID
If this is part of a MSA enter MSA Contract ID
Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in
OnBase
Contract Dates
Effective Date Review Date*
04'08/2021
Termination Notice Period Committed Delive
Expiration Date*
06/08/2021
Contact_ Information
Contact Info
Contact Name
Purchasing
Purchasing Approver
Approval Process
Department Head
JAMIE ULRICH
DH Approved Date
06/2912020
Final Approval
BOCC Approved
BOCC Signed Date
BOCC Agenda Date
07/08/2020
Originator
CULLINTA
Contact Type Contact Email
Finance Approver
BARB CONNOLLY
Contact Phone 1 Contact Phone 2
Purchasing Approved Date
Finance Approved Date
06130/2020
Tyler Ref #
AG 070820
Legal Counsel
GABE KALOUSEK
Legal Counsel Approved Date
06/30/2020
Submit
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