HomeMy WebLinkAbout20163569.tiffCOLORADO
Office of Children.
Youth 8 Families
INDIVIDUAL PROVIDER CONTRACT
FOR PURCHASE OF FOSTER CARE SERVICES IN A FOSTER CARE HOME
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1. THIS CONTRACT AND AGREEMENT, made this date,` ��� W o(Y O2 0/6 by and between the Weld County
Department of Human Services, P. O. Box A, Greeley, CO 80032, hereinafter called "County Department" and
Manore, Sarah and Brian," 50 S. Dickson Street, Keenesburg, CO 80643 hereinafter called "Provider.
2. This Contract and Agreement shall be effective from July 1, 2016 and continue in force until June 30, 2017 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 certificate as a: ® Foster Care Home or O Kinship Foster Care Home (check applicable
blank). 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;
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.
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1575 Sherman Street, 2nd Floor. Denver, CO 80203 P 303-866.5932 F 303-866.5536 www.colorado.gov/cdhs
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John W. Hickenloo r, Gov nor I Re gi xecutive Director
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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 in accordance with Volume 7
requirements.
21. To complete or schedule a medical examination for the child or youth within 14 days after initial placement and a
dental the County Department;
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;
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1575 Sherman Street, 2nd Floor. Denver, CO 80203 P 303.866.5932 F 303.866.5536 www.cotorado.gov/cdhs
John W. Hickenlooper. Governor I Reggie Bicha, Executive Director
C
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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.
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.
Toilynn Edwards
7/1/2016
County Department (type or print) Signature
Date
WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above.
C UNTY: �
ATTEST:jd,d/tf �i• ..�,��►►C.,//O; BOARD OF COUNTY COMMISSIONERS
WeldClerk to the Bo- rd WELD COUNTY, COLORADO
By:
Deputy ! lerk
PROVIDER:
Provider (type or print)
Provider (type or print)
ike Freeman, Chair NOV 2 8 2016
Signature
(d /4a f i(p
Date
ie
ate
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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
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 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 Manore, Sarah and Brian, hereinafter referred to as, "Contractor."
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. 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.
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 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 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. Contractor understands that the State
Department and the County may provide consultation to Contractor to assure satisfactory
performance in the provision of purchased services under this Agreement.
6. County shall have access to Contractor'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.
8. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to
Exhibit A o the CWS-7A
4 Revised 612016
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 this Agreement.
10. This Agreement is nonexclusive and County may engage or use other contractors or persons to
perform services of the same or similar nature.
11. Contractor certifies, warrants, and agrees that it does not knowingly employ or contract with an
illegal alien who will perform work under this contract. Contractor 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). Contractor shall not knowingly
employ or contract with an illegal alien to perform work under this Agreement or enter into a
contract with a subcontractor that fails to certify with Contractor that the subcontractor shall not
knowingly employ or contract with an illegal alien to perform work under this Agreement.
Contractor 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
Contractor obtains actual knowledge that a subcontractor performing work under the public
contract for services knowingly employs or contracts with an illegal alien Contractor shall notify
the subcontractor and County within three (3) days that Contractor has actual knowledge that a
subcontractor is employing or contracting with an illegal alien and shall terminate the subcontract
if a subcontractor does not stop employing or contracting with the illegal alien within three (3)
days of receiving notice. Contractor shall not terminate the contract if within three days the
subcontractor provides information to establish that the subcontractor has not knowingly
employed or contracted with an illegal alien. Contractor 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 Contractor participates in the State of
Colorado program, Contract Professional shall, within twenty days after hiring an new employee
to perform work under the contract, affirm that Contractor 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. Contractor 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 Contractor 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, Contractor 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
Contractor receives federal or state funds under the contract, Contractor 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 Contractor 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. Contractor 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 o the CWS-7A
5 Revised 6/2016
0. 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.
13. In addition to terminating this Agreement, in accordance with the provisions of this Agreement
and Exhibit A, County may exercise the following remedial actions if the County finds and
determines that the Contractor 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
Contractor. These remedial actions include, but are not limited to, any one or more of the
following:
A. Withhold payment to 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 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.
C. 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.
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 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.
16. 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.
17. 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. Contractor 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 Contractor 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 Contractor unless otherwise negotiated and approved by the County.
20. 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 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# 1679501. These services
Exhibit A o the CWS-7A
6 Revised 6/2016
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, including hospitalization. Bed hold requests must have prior written
authorization from the Department Administrator before payment will be release to Contractor.
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 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.
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).
24. 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.
CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of Human
Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State
of Colorado and any applicable federal laws and regulations, as such, which may be amended
from time to time, and shall be binding on Contractor and control any disputes in this Agreement.
2. 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 at least
$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. Contractor 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
Exhibit A o the CWS-7A
7 Revised 6/20I6
requested by the Department. County staff shall notify the Contractor 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 Contractor'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 attend court
hearings as requested.
9. 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.
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 a monthly
basis and signed off by child's caseworker and/or the Contractor'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 o the CWS-7A
8 Revised 6/2016
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?
Select One
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
P4. How
scheduling
monitoring
often does the child require special and extensive involvement by the provider in
Select One
and
of time and/or activities and/or crisis management?
P5. How
appropriate
much time is the provider required to assist the child
aae
because of impairments beyond
Select One
and/or occupational therapy?
needs with feeding, bathing, grooming, physical,
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
Ti. How
NBC (NEEDS
often are therapy services needed to address child's individual needs per NBC
Select One
assessment?
BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas:
Comment:
Rating:
❑
Aggression/Cruelty to Animals
Select One
❑
Verbal or Physical Threatening
Select One
❑
Destructive of Property/Fire Setting
Select One
❑
Stealing
Select One
•
Self -injurious Behavior
Select One
❑
Substance Abuse
Select One
❑
Presence of Psychiatric Symptoms/Conditions
Select One
Select One
REnuresis/Encopresis
Runaway
Select One
❑
Sexual Offenses
Select One
❑
Inappropriate Sexual Behavior
Select One
❑
Disruptive Behavior
Select One
❑
Delinquent Behavior
Select One
❑
Depressive -like Behavior
Select One
Medical Needs - (If condition is rated "severe",
please complete the Medically fragile NBC)
Select One
•
❑
Emancipation
Select One
❑
Eating Problems
Select One
❑
Boundary Issues
Select One
❑
Requires Night Care
Select One
❑
Education
Select One
❑
Involvement with Child's Family
Select One
Addendum 1
9
Revised 6/2016
ADDENDUM 2
Needs Based Care Rate Table
Weld County Department of Human Service
(Effective 7/01/2015)
Age 0-10...$17.01
11-14...$18 81
Age 15-21...$20.09
$•66
<".
$0.00
Not needed or cover
under Medicaid.
, ,.
County Basic
MaintenanceAge
Rate
$12.35
No crisis intervention, Minimal
CPA involvement, one face -to -
face visit with child per month.
f '
-----
1
$20.56
$.66
$15.77
Minimal crisis intervention as
needed, one face-to-face visit per
month with child, 2-3 contacts per
month
$5.14
Regularly Scheduled
therapy up to 4
hours/month.
$3.45
1 V2
$23.99
$.66
$17.48
-_ ----- —
2
$27.42
$ 66
$19.20
Occasional crisis intervention as
needed, two face-to-face visits
child, 2-3 contacts per month
$10.28
Weekly scheduled
therapy 5-8 hours a
month with 4 hours ofwith
group therapy.
$4.97
2 Yi
$30.85
$.66
$20.91
-
—
-----
3
$34.27
$.66
$22.62
Ongoing crisis intervention as
needed, weekly face-to-face visits
with child, and intensive
coordination of multiple services.
$15.42
Regularly scheduled
weekly, multiple
sessions, can include
more than 1 person, i.e.
family therapy, for 9-12
hours/monthly.
$6.50
31/2
$37.69
$.66
:rs
$24.34
4
Congregatee
Drop Down
Assessment/
Emergency
Level Rate
$41 13
$27.42
$.66;.
x'
$26.05
Ongoing crisis intervention as
needed, which includes high level
of case management and CPA
involvement with child and
provider and 2-3 face -to face
contacts per week minimum.
Negotiated
'
Negotiated
$.66
'
$19.20
------
Addendum 2
10
Revised 6/2016
RESOLUTION
RE: APPROVE INDIVIDUAL PROVIDER CONTRACT FOR PURCHASE OF FOSTER CARE
SERVICES IN A FOSTER CARE HOME AND AUTHORIZE CHAIR TO SIGN - SARAH
AND BRIAN MANORE
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 Sarah and Brian Manore, commencing June 23, 2016, and
ending June 30, 2016, 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
Sarah and Brian Manore, be and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair Pro-Tem 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 21st day of November, A.D., 2016, nunc pro tunc June 23, 2016.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST:d� a` , C jeigo of
Weld County Clerk to the Board
a
APP
puty Clerk to the Board
ounty Attorney
Date of signature: (Di( N / (Co
EXCUSED
Mike Freeman, Chair
Sean P. Conway, Pro-Tem
Cc I-IS(cnI38/3.6)
(a/ (S/ (Co
2016-3569
HR0087
MEMORANDUM
DATE: October 31, 2016
TO: Board of County Commissioners — Pass -Around
FR: Judy A. Griego, Director, Human Services
RE: Weld County Department of Human Services' Individual
Provider Contract for Purpose of Foster Care Services in a
Foster Care Home Agreements
Please review and indicate if you would like a work session prior to placing these items on the
Board's agenda.
Request Board Approval of the Department's Individual Provider Contract for Purpose of
Foster Care Services in a Foster Care Home Agreements. The major provisions for these
Agreements are as follows:
No.
Provider/Term
Facility Type/Location
Rate
1
Manore, Sarah and Brian
June 23, 2016 and continue in force until June
30, 2016 or until the facility certificate is
revoked or surrendered
County Foster Care Home
Keenesburg, CO 80643
Negotiated
based on
child needs
2
Long, Kiley and Cole, Andrew
September 30. 2016 and continue in force
until June 30, 2017 or until the facility
certificate is revoked or surrendered
County Foster Care Home
Milliken, CO 80543
Negotiated
based on
child needs
I do not recommend a Work Session. I recommend approval of this Agreement.
Approve Request
BOCC Agenda Work Session
Sean Conway
Steve Moreno
Barbara Kirkmeyer
Mike Freeman
Julie Cozad
Pass -Around Memorandum; October 31, 2016 - ID 828, 852 Page 1
LU/dYof sag
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
er
THIS AGREEMENT is made this c)2Pday of 11.41 , 20 I , 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 Manore, Sarah and Brian, whose address is 50 S. Dickson
Street, Keenesburg, CO 80643, hereinafter referred to as, "Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Provider has read and is fully familiar with the Minimum Rules and
Regulations for Family Foster Homes and/or Specialized Group Care Facilities issued by the
Colorado Department of Humans Services and holds a valid certificate/license as a Family Foster
Home with which such certification standards that shall be maintained during the term hereof
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 certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
1. TERM:
A. The term of this Agreement shall be from June 23, 2016, to and until June 30,
2016, or until the facility 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.
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.
2016-3569
CWS-7A Individual Provider Contract I Revised 6/2015
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.
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.
CWS-7A Individual Provider Contract
2 Revised 6/2015
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
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 $500,000 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
CWS-7A Individual Provider Contract
3 Revised 6/2015
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.
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.
CWS-7A Individual Provider Contract
4 Revised 6/2015
1 1. 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.
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 Exhibit A and 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, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, 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.
E. The State of Colorado Department of Human Services and the County 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 and the County may provide consultation to
CWS-7A Individual Provider Contract
5 Revised 6/2015
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.
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. Contract Professional certifies, warrants, and agrees that it does not knowingly employ
or contract with an illegal alien who will perform work under this contract. Contract
Professional 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-I 7.5-102(5)(c). Contract Professional shall not
knowingly employ or contract with an illegal alien to perform work under this
Agreement or enter into a contract with a subcontractor that fails to certify with
Contract Professional that the subcontractor shall not knowingly employ or contract
with an illegal alien to perform work under this Agreement. Contract Professional
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 Contract Professional obtains actual knowledge that a subcontractor performing
work under the public contract for services knowingly employs or contracts with an
illegal alien Contract Professional shall notify the subcontractor and County within
three (3) days that Contract Professional has actual knowledge that a subcontractor is
employing or contracting with an illegal alien and shall terminate the subcontract if a
subcontractor does not stop employing or contracting with the illegal alien within
three (3) days of receiving notice. Contract Professional shall not terminate the
contract if within three days the subcontractor provides information to establish that
the subcontractor has not knowingly employed or contracted with an illegal alien.
Contract Professional shall comply with reasonable requests made in the course of an
investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the Colorado
Department of Labor and Employment. If Contract Professional participates in the
State of Colorado program, Contract Professional shall, within twenty days after hiring
an new employee to perform work under the contract, affirm that Contract
Professional has examined the legal work status of such employee, retained file copies
of the documents, and not altered or falsified the identification documents for such
employees. Contract Professional shall deliver to County, a written notarized
CWS-7A Individual Provider Contract
6 Revised 6./2015
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
Contract Professional 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, Contract Professional 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 Contract Professional receives federal or state funds under the contract,
Contract Professional 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 Contract Professional operates as a sole proprietor, it hereby swears or affirms under
penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully
present in the United States pursuant to federal law, (b) shall produce 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.
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.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work 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 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
CWS-7A Individual Provider Contract
7 Revised 6/2015
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.
R. Any amendments or modifications to this agreement shall be in writing signed by
both parties.
S. 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.
T. Contractor shall strictly comply with all applicable federal and State laws, rules and
regulations in effect or hereafter established
U. 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.
CWS-7A Individual Provider Contract
8 Revised 6/2015
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
(� �� // / COUNTY:
ATTEST: f/ �-e-S;� BOARD OF COUNTY COMMISSIONERS
Weld .0 tv lerk to the Boa d WELD COUNTY, COLORADO
B
Deputy
C vClic—
Sean P. Conway, Pro -Tern NOV 21 201E
ONTRACTOR:
Manore, Sarah and Brian
077 F Wt ,i/ 50 S. Dickson Street
�• Keenesburg, CO 80643
By: - v, /) )1111/1V -C6/23/2016
Contractor's (or designee's) Signature
and Date
By: 6/23/2016
Contractor's (or designee's) Signature
and Date
CWS-7A Individual Provider Contract
9 Revised 6/2015
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 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 Manore, Sarah and Brian, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit shall be used to determine the Child Maintenance and
Medical Needs, if applicable, for each child placed with Contractor unless the child is
placed in a County certified kinship foster care home or 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 for Child Maintenance as indicated
on the Needs Based Care Rate Table, designated in this exhibit as, 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 the Child Maintenance level of
service, as indicated by the Needs Based Care Rate Table, designated within this exhibit,
for children placed within the Weld County Certified Foster Care Home identified as
Provider ID# 1679501. 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 7 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.
CWS-7A Individual Provider Contract
10 Revised 6/2015
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, 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.
CONTRACTOR SHALL:
1. 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.
2. 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.
3. 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, and comply with the treatment
plan of the child.
4. 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.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. 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.
7. Maintain, access and review information weekly on FIDOS.
CWS-7A Individual Provider Contract
11 Revised 6/2015
8. 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.
9. 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.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
1 l . Maintain behavior observation notes as required by the level of care assessed for each
child.
12. 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.
CWS-7A Individual Provider Contract
12 Revised 6/2015
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?
Select One
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
P4. How often does the child require special and extensive involvement by the provider in scheduling
Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond age
Select One
appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy?
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 theraservices needed to address child's individual needs . r NBC assessment?
Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas:
Comment:
Rating:
❑
Aggression/Cruelty to Animals
Select One
❑
Verbal or Physical Threatening
Select One
Destructive of Property/Fire Setting
Select One
Stealing
Select One
Self -injurious Behavior
Select One
0
Substance Abuse
Select One
❑
Presence of Psychiatric Symptoms/Conditions
Select One
❑
Enuresis/Encopresis
Select One
Runaway
Select One
C
Sexual Offenses
Select One
❑
Inappropriate Sexual Behavior
Select One
❑
Disruptive Behavior
Select One
❑
Delinquent Behavior
Select One
❑
Depressive -like Behavior
Select One
Medical Needs - (If condition is rated "severe", please
complete the Medically fragile NBC)
Select One
❑
Emancipation
Select One
❑
Eating Problems
Select One
❑
Boundary Issues
Select One
•
Requires Night Care
Select One
❑
Education
Select One
0
Involvement with Child's Family
Select One
Exhibit B to the Additional Provisions 13
Revised 6/2014
Needs Based Care Rate Table
Weld County Department of Human Service
(Effective 7/01/2015)
F i
s J) +. ai�4
La"'a:•.4ei 'a o°!f-
b.a Su ...hi:.;`mn.���r
,<< f,-
,.,.,..: = _.:;.
County Basic
Maintenance
Rate
Age 0-10...$17 01
'
Age 11-14...$18 81
g
Age 15-21...$20 09
Y
$•66
'
ti ;
3. $12.35
No crisis intervention, Minimal
CPA involvement, one face -to-
face visit with child per month.4'9g
r'
t ;1
ss^
$0.00
Not needed or cover
under Medicaid.
� �.
f ii
u
$20.56
3 ,?
$.66
$15.77
Minimal crisis intervention as
needed, one face-to-face visit
per month with child, 2-3
contacts per month
y
,w
. '
3 , :,
$5.14
Regularly Scheduled
therapy up to 4
hours/month.
$3.45
I '/:
$23.99
$.66
$17.48
2
:er
$27.42
awn
$.66
i u'
$19.20
Occasional crisis intervention as
needed, two face-to-face visits
with child, 2-3 contacts per
month
t !
'
}
$10.28
Weekly scheduled
therapy 5-8 hours a
month with 4 hours of
group therapy.
�`
s A
$4.97
2 /
$30.85
$.66
$20.91
3
i _
$34.27
r ,;
$.66
s
4.
$22.62
Ongoing crisis intervention as
needed, weekly face-to-face
visits with child. and intensive
coordination of multiple
services.
x �,
s
t r
$15.42
Regularly scheduled
weekly, multiple
sessions. can include
more than 1 person
i.e. family therapy, for
9-12 hours/monthly
ill
g
$6.50
31/2
$37.69
}
$.66
$24.34
4
Congregate
Care
Drop Down
,,
v
4+
t-
$41.13
'in
'
$.66
$26.05
Ongoing crisis intervention as
g g:
needed, which includes high
level of case management and
CPA involvement with child and
provider and 2-3 face -to face
contacts per week minimum.
'2-
Negotiated t
`-.
Negotiated
r3�i1`Xi'-.l
.k'. �._. �..
?
•erg
� :.e.5ie�i;:..v _ .
� _ ..
_ t
�
` .a^Y i t . . uue
- k•,1
Assessment/
Emergency
Level Rate
$27.42
hs
:at
$.66
.
f
$19.20
A
n
CWS-7A Individual Provider Contract I4
Revised 6/2015
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