HomeMy WebLinkAbout20150457.tiff 1861 MEMORANDUM
DATE: February 4, 2015
G 0 N T Y TO: Barbara Kirkmeyer, Chair, Board of County Commjzsio rs
FROM: Judy A. Griego, Director, Human Se 'c ep l/ Yen
RE: Respite Service Agreement between th eld County
Department of Human Services and Pam Kliewer for Consent
Agenda
Enclosed for Board approval is a Respite Service Agreement between the Department and Pam
Kliewer. The boiler-plate agreement was reviewed under the Board's Pass-Around
Memorandum dated July 15, 2014, and approved for placement on the Board's Consent
Agenda.
Below are the major provisions of the attached Agreement:
No. Provider/Term Service/Funding Source Rate
1 Pam Kliewer Respite Care $16.75/each four hour
period, may not exceed
1 year; date determined upon the $67.00/month for 16
execution of this agreement. hours—per child.
If you have questions, please give me a call at extension 6510.
2015 0457
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AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY,
ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES,AND
RESPITE CARE PROVIDER,PAM KLIEWER
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THIS AGREEMENT is made and entered into this II�d y of2015 by and between
the Board of County Commissioners of the County of Weld, State of Colorado, on behalf of the
Weld County Department of Human Services, whose address is 1150 "O" Street, Greeley,
Colorado 80631, hereinafter referred to as "County", and Pam Kliewer, whose address is 10473
Taylor Avenue,Firestone, Colorado 80504, hereinafter referred to as "Care Provider."
WITNESSETH:
WHEREAS,required approval,clearance, and coordination have been accomplished from
and with appropriate agencies; and
WHEREAS,the Colorado Department of Human Services has provided funding to the
County for respite care for Weld County certified foster care homes; and
WHEREAS, County has determined that due to the significant challenges often
experienced by certified foster care providers, it is necessary to offer them respite services, as
described in Exhibit A, "Scope of Services", a copy of which is attached hereto and made a part
hereof by this reference),to allow them to continue to provide high quality care for the children in
their charge, and
WHEREAS, Care Provider is willing and able to abide by the terms and conditions
required by County, as more fully set forth in this Agreement,
WHEREAS, Care Provider is able and available to provide respite services as defined in
this Agreement at the rates set forth in Exhibit B, "Rate of Reimbursement" a copy of which is
attached hereto and made a part hereof by this reference),
NOW, THEREFORE, in consideration of the mutual promises and covenants contained
herein,the parties hereto agree as follows:
RESPITE CARE PROVIDER'S RIGHTS AND RESPONSIBILITIES:
1. As used in this Agreement "Respite Care" is defined as those child care services
required by one or more children who are in the care of a certified foster home,
which services are provided by Care Provider in order to give foster parents an
opportunity to address matters which cannot be addressed while caring for the
child(ren) in their care. These services are described in Exhibit A. These services
may also include transporting the child to school and other appointments
previously arranged by the foster parent.Transportation services are provided at
the sole risk, responsibility and liability of Care Provider.
Page 1of10
2. Care Provider may provide up to sixteen (16) hours of Respite Care per child per
month for certified Weld County foster homes seeking respite care,as approved by
the Department. The hours of respite care may be provided in any combination
(schedule) throughout the month so long as the total hours provided does not
exceed sixteen(16)hours per month.
3. At all times from the effective date of the Agreement until completion of the
Agreement, Care Provider shall comply with the administrative requirements, cost
principles and other requirements set forth in the Financial Management Manual
adopted by the State of Colorado. The required annual audit of all funds expended
under this Agreement must conform to the Single Audit Act of 1984 and OMG
Circular A-133.
4. Care Provider agrees to accept payment by either County warrant or ACH direct
deposit.
5. Care Provider agrees to obtain a criminal background check, and warrants that if
any previous criminal charge filed against Care Provider does not appear in the
background check, he/she shall disclose such charges.
6. Care Provider assures that it will fully comply with all applicable Federal and State
laws which govern the ability of the County to comply with the relevant funding
requirements.
7. Care Provider assures and certifies as follows:
a. He/She is not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation with any
program with a Federal or State department or agency; and
b. He/She has not, within a three-year period preceding this Agreement, been
convicted of or had a civil judgment rendered against him/her for
commission of fraud or criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State or Local),
transaction or contract under public transaction; or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of
records, making false statements, or receiving stolen property;and
c. He/She is 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 this certification; and
d. He/She has not, within a three-year period preceding this Agreement, had
one or more public transactions (federal, state, or local) terminated for
cause or default.
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8. Care Provider certifies that he/she is in compliance with the provisions of the
Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq., and hereby affirms under
penalty of perjury that he/she is a citizen of the United States or is otherwise
lawfully present in the United States. Care Provider agrees to produce one or more
forms or identification as required by the Department, in order to affirm his/her
legal status. Care Provider further affirms that he/she is not an illegal alien. If Care
Provider fails to comply with any of the above requirements, the Department may
terminate this Agreement for breach and Care Provider shall be liable for actual and
consequential damages to the Department.
9. Care Provider certifies that, at the time of entering into this Agreement, he/she has
currently in effect all necessary licenses, approvals, insurance, etc., required to
properly provide the services covered by this Agreement. These requirements
include the following:
a. Current Colorado driver's license indicating Care Provider is at least
eighteen (18) years of age; and
b. Completed fingerprint card for a background check through the Colorado
Bureau of Investigation (CBI) and the Federal Bureau of Investigation
(FBI). The fingerprinting expense must be paid by the Care Provider.
Background checks will be paid by the County.
c. Current CPR and First Aid certifications. If either certification expires
during the term of this Agreement, Care Provider shall renew the
certification ensuring that there is no lapse in certification. County will
pay for certification through select CPR and First Aid trainers identified by
the County.
d. Care Provider shall procure at least the minimum amount of automobile
liability insurance required by the State of Colorado. County provides no
automobile liability coverage for Care Provider. Proof of said automobile
liability insurance shall be provided to County prior to the performance of
any services under this Agreement.
e. Copies of all documentation relating to the foregoing requirements shall be
provided to the County by Care Provider prior to the performance of any
services covered under this Agreement. County shall determine eligibility
for certification based upon the successful completion of all required
training and receipt of current documentation.
10. Care Provider shall attend fifteen (15) hours PRIDE training through the Weld
County Department of Human Services prior to the performance of services under
this Agreement. County shall not compensate Care Provider for said training;
including time spent traveling to and from training, time spent in attendance of the
training, or any associated costs paid by Care Provider for such training, unless
Page 3 of 10
specifically agreed to in writing in advance by County.
11. Care Provider shall indemnify, defend and hold harmless Weld County,the Board
of County Commissioners of Weld County, its employees, volunteers and agents
for any damages caused by his/her actions while performing services pursuant to
this Agreement, and shall hold County harmless from any loss occasioned as a
result of the performance of this Agreement.
12. Care Provider shall be totally responsible to provide whatever personal liability
and/or other insurances, he/she deems necessary to cover his/her personal liability
for any injuries caused by Care Provider in the course of providing services under
this Agreement.
13. Care Provider shall perform his/her duties hereunder as an independent contractor
and not as an employee of County. Care Provider shall be solely responsible for
his/her acts performed pursuant to this Agreement. Under no circumstances shall
Care Provider be deemed to be an agent or employee of Weld County. Care
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 Care Provider. Unemployment insurance benefits will
not be available to Care Provider for services provided under this Agreement.Care
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.
14. Care Provider shall not have authorization, express or implied, to bind County to
any agreement, liability or understanding.
15. Care Provider agrees that he/she shall not use alcohol, illegal drugs, marijuana,
whether for recreational or medical purposes, or any other drugs which have the
potential of impacting Care Provider's ability to supervise the children in his/her
care while providing services under this Agreement or within five(5)hours prior to
the provision of said services.
16. Care Provider shall protect the confidentiality of all records and other materials to
which he/she has access relating to the foster family and child(ren)to whom the
services are provided, which are maintained in accordance with this Agreement
except for purposes directly connected with the administration of Child Protection.
COUNTY'S RIGHTS AND RESPONSIBILITIES:
1. Weld County, the Board of County Commissioners of Weld County, its officers
and employees, shall not be held liable for injuries or damages caused by any
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negligent acts or omissions of Care Provider while performing duties described in
this Agreement.
2. County shall not indemnify Care Provider for any loss incurred by Care Provider as
a result of services performed under this Agreement.
3. County shall pay Care Provider in accordance with the terms set forth in Exhibit B,
reference),as long as services are rendered satisfactorily and in accordance with the
Agreement.
4. Payment pursuant to this Agreement is subject to, and contingent upon, the
continuing availability of funds made available for the purposes hereof.No portion
of this Agreement shall be deemed to create an obligation on the part of County to
expend funds not otherwise appropriated. The County may terminate this
Agreement at any time if said source of funding is no longer available to County
5. County may withhold payment under this Agreement if Care Provider fails to
comply with any part of the Agreement. In the event County withholds payment,
Care Provider may appeal such circumstance in writing to the Weld County
Director of Human Services. The decision of the Weld County Director of Human
Services shall be final.
.GENERAL PROVISIONS:
1. The term of this Agreement shall commence on the date of County's execution of
this Agreement and shall continue for a period of one(1)year.This Agreement may
be renewed by the mutual agreement of the parties for up to three(3)additional one
(1) year periods. Renewal of the Agreement shall be documented by the execution
of the "Renewal of Agreement" form, a copy of which is attached hereto as
"Exhibit C"and made a part hereof by this reference.
2. Either party may terminate this Agreement at any time by providing the other party
with a 30-day written notice thereof. Furthermore, this Agreement may be
terminated by County at any time without notice upon a material breach by Care
Provider of the terms of the Agreement.
3. Care Provider may not assign or transfer this Agreement, any interest therein or
claim hereunder, without the prior written approval of County.
4. 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 and nothing 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
Page 5 of 10
that any entity other than the undersigned parties receiving services or benefits
under this Agreement shall be an incidental beneficiary only.
5. No term or condition of this contract shall be construed or interpreted as a waiver,
express or implied, of any of the immunities, rights, benefits, protections or other
provisions, of the Colorado Governmental Immunity Act of§§24-10-101 et. seq.,
as applicable now or hereafter amended.
6. If any section, subsection,paragraph, sentence,clause, or phrase of this Agreement
is for any reason held or decided to be unconstitutional, such decision shall not
affect the validity of the remaining portions. The parties hereto declare that they
would have entered into this Agreement and each and every section, subsection,
paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one
or more sections, subsections, paragraphs, sentences, clauses, or phrases might be
declared to be unconstitutional or invalid.
7. No officer, member or employee of County and no member of their governing
bodies shall have any pecuniary interest, direct or indirect, in the approved
Agreement or the proceeds thereof.The appearance of conflict of interest applies to
the relationship of a Care Provider with County when the Care Provider also
maintains a relationship with a third party and the two relationships are in
opposition. In order to create the appearance of a conflict of interest, it is not
necessary that the Care Provider gain from knowledge of these opposing interests.
It is only necessary that the Care Provider knows that the two relationships are in
opposition. During the term of the Agreement, Care Provider shall not enter into
any third party relationship that gives the appearance of creating a conflict of
interest. Upon learning of an existing appearance of a conflict of interest situation,
Care Provider shall submit to the Department, a full disclosure statement setting
forth the details that create the appearance of a conflict of interest. Failure to
promptly submit a disclosure statement required by this paragraph shall constitute
grounds for the Department's termination, for cause, of its Agreement with the
Care Provider. Care Provider certifies that no Federally appropriated funds have
been paid or will be paid, by or on behalf of Care Provider, to any person for
influencing or attempting to influence an officer or employee of an agency, a
Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the awarding of any Federal contract, the
making of any Federal grant, the making of any Federal loan, the entering into of
any cooperative agreement, and the extension, continuation, renewal, amendment,
or modification of an Federal contract, loan, grant, or cooperative agreement.
8. This Agreement, together with Exhibits A, B, and C, constitutes the entire
understanding between the parties with respect to the subject matter hereof, and
may not be changed or modified, unless by a written amendment executed by both
Page 6 of 10
parties. This Agreement shall be binding upon the parties hereto,their successors,
heirs, legal representatives, and assigns. Neither County nor Care Provider may
assign any of its rights or obligations hereunder without the prior consent of the
other party.
9. This Agreement shall not be valid until it has been approved by the Board of
County Commissioners of Weld County,Colorado.
10. Colorado law, and rules and regulations established pursuant thereto, shall be
applied in the interpretation, execution, and enforcement of this Agreement. Any
provision included or incorporated herein by reference which conflicts with said
laws, rules and/or regulations shall be null and void. In the event of a legal dispute
between the parties,Care Provider agrees that the Weld County District Court shall
have exclusive jurisdiction to resolve said dispute.
11. In the event of a dispute between County and Care Provider, concerning this
Agreement,the parties agree that each party shall be responsible for the payment of
attorney fees and/or legal costs incurred by or on its own behalf.
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the
day,month,and year first above written.
A E T: p IE BOARD OF COUNTY COMMISSIONERS
�C WELD COUNTY,CO RADO
Weld County Clerk tot o
rbara, Kirkmeyer, ,chair FEB 11 2015
By:
Deputy erk to the Bo. -
APP TO ORM: APPROVED AS TO FUNDING:
44�
ount [torn Controller
WELD COUNTY DE A MENT PAM KLI WE /{L
_"
By: By:
J A. Gri go,D. ctor Pam Kliewer
Page 7 of 10
028 ,1 -O 4/67
EXHIBIT A
SCOPE OF SERVICES
1. Care Provider will provide up to sixteen (16)hours of Respite care services per month per
child for foster children residing in Weld County certified foster homes.
2. Care Provider will, at the time of entering into this Agreement, ensure he/she has
completed all the necessary paperwork and has in effect all necessary licenses, approvals,
insurance, etc., required to provide the Respite services covered by this Agreement. Care
Provider will have:
a. Completed and submitted the Colorado Department of Human Services
Application and signed as "Foster Parent/Home" PRIOR to completing the
PRIDE classes.
b. Successfully completed fifteen (15) hours PRIDE training through the
County prior to the performance of services under this Agreement.
c. Provided a copy of their current Colorado driver's license indicating Care
Provider is at least eighteen(18) years of age; and
d. Completed and submitted a fingerprint card for a background check through
the Colorado Bureau of Investigation (CBI) and the Federal Bureau of
Investigation (FBI). The fingerprinting expense must be paid by the Care
Provider. Background checks will be paid by the County.
e. Provided three (3) reference forms completed by non-relatives.
f. Provided proof of current CPR and First Aid certifications.
g. Completed and signed Confidentiality, Discipline and Mandated Reporter
Policies.
h. Provided proof that Care Provider has procured at least the minimum
amount of automobile liability insurance required by the State of Colorado.
County provides no automobile liability coverage for Care Provider.
Copies of all documentation relating to the foregoing requirements shall be provided to the
County by Care Provider prior to the performance of any services covered under this
Agreement. County shall determine eligibility for certification based upon the successful
completion of all required training and receipt of current documentation.
Care Provider further acknowledges that he/she will remain current with all documentation
or certifications for the term of this Agreement. Should an item expire or otherwise
become invalid, Care Provider will submit current documentation to the County to avoid a
lapse in documentation and/or certification.
Page 8 of 10
3. Care Provider acknowledges that the County shall not compensate Care Provider for said
training; including time spent traveling to and from training,time spent in attendance at the
training,or any associated costs paid by Care Provider for such training, unless specifically
agreed to in writing in advance by County.
4. Care Provider acknowledges that arrangements to provide Respite services must be
communicated to the child's Caseworker and the Foster Care Coordinator prior to Respite
taking place in order to discuss arrangements and ensure all the child's needs are met.
5. Care Provider will become familiar with and follow all the State and Federal rules and
regulations as applicable to the services provided under this Agreement.
6. Care Provider will complete and submit the Respite Care Payment Form each month by the
10th of the month following the month of service. The Respite Care Payment Form is
available on the Foster Parents Internet Database and On-line System (FIDOS).
Page 9 of 10
EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
The County agrees to reimburse the Care Provider in consideration of the work and services
performed under this Agreement at the rate specified in Paragraph 2, below. The total
amount to be paid to the Care Provider during the term of this Agreement shall be reported by
the County after June 30, 2015.
Expenses incurred by the Care Provider prior to the term of this agreement are not eligible
County expenditures and shall not be reimbursed by the County.
Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent
upon the continuing availability of said funds for the purposes hereof. In the event that said
funds, or any part thereof, become unavailable as determined by the County, the County may
immediately terminate the Agreement or amend it accordingly.
2. Fees for Services
Respite care is limited to four(4) hours per week per child. The hours of care may be
provided in any combination throughout a month, but may not exceed 16 hours per month.
Payment will be$16.75 per each four hour period, but may not exceed $67.00 per month for
16 hours.
Human Services referrals will not be sent to collections by Care Provider for default of
co-pay/fees. Services will be performed regardless of client's refusal or inability to pay
co-pay.
Care Provider will collect any applicable sliding scale co-pays and credit Human Services for
any payments received on the monthly billing statements.
3. Submittal of Vouchers
Care Provider shall prepare and submit a Respite Care Payment Form each month to certify that
the services authorized were provided on the date(s) indicated and the charges made were
pursuant to the terms and conditions of Exhibit A. The Respite Care Payment Form is
available online through the Foster Parent Internet Database and On-line System(FIDOS).
Page 10of10
t
Declaration of Independent Contractor Status Form
We certify UNDER PENALTY OF PERJURY that:(name and trade name) P("� TY) El e Ckr—
performing(type of work) R e 5 p;f-e c ca,"e r��
Social Security or Feder ail Empl er Idet tificatljon# csal—4,1—Jg 'w
Address:`047'3 role) �Je..T ceitcu4Cc &fOl.! Phone: 3 —34c--3339
is an independent con ctor(IC)and is not an employee of the following policyholder(PH):
Address: Policy# Phone:
We also certify,by OUR initials WHERE APPLICABLE,that the above business for which the above individual performs services
meej he following criteria:
IC VI H. 1.The business DOES NOT require the individual to work ONLY for the business for whom services are performed
(except that the individual may DECIDE to work only for the business for a definite period);
IC 9k—PEI 2.The business DOES NOT establish a quality standard for the individual(except that the business may provide
plans and specifications regarding work but cannot oversee the actual work or instruct the individual as to how work
will be performed);
IC O . PH 3.The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate;
IC Vic--PH 4.The business DOES NOT terminate the work or the service provided during the contract period unless the
individual violates the terms of the contract or fails to produce a result that meets the specifications of the contract;
IC KPH 5.The business DOES NOT provide more than minimal training for the individual;
IC• EL—PH 6.The business DOES NOT provide tools or benefits to the individual(except that materials and equipment may be
rn supplied):
IC f It—PH 7.The business DOES NOT dictate the time of performance(except that a completion schedule and a range of
�}f agreeable work hours may be established);
IC t'UL PH 8.The business DOES NOT pay the individual personally instead of making payment or checks payable to the trade
or business name of the individual;
IC Pk PH 9.The business DOES NOT combine the business operations in any way with the individual's business operations
instead of maintaining all such operations separately and distinctly.
CERTIFICATION BY INDEPENDENT CONTRACTOR
THE INDEPENDENT CONTRACTOR UNDERSTANDS THAT HEISHE:
•WILL NOT BE ENTITLED TO ANY WORKERS'COMPENSATION BENEFITS IN THE EVENT OF INJURY.
�S OBLIGATED TO PAY ALL FEDERAL AND STATE INCOME TAX ON ALL MONEY EARNED WHILE PERFORMING SERVICES OR THE a
BUSINESS.
•IS EQUI D TO PROVIDE RKE S'COMPEN ATION INSURAN F ALL WORKERS THAT H HE HI E .
ti. ,�MO
COrC Rug Oar 6 al-14-/41a4,
Independent Contractor Signature Title Social Security# X 6 G
STATE OF COLORADO,COUNTY OF , p
Sub ' ed and sw me by (O l .vie this 02 day of. ` NI
V.
/ -r Commission expires: ' G f
NO rUnLl L
Acceptance of the Independent Contractor named on this form does not change any party's responsibility under the Workers'Compensation Act.ff
individuals or organizations hired or contracted by the Independent Contractor are not covered by other workers'compensation insurance,the policyholder
specified on this form will be charged premium for coverage of those individuals or organizations.
CERTIFICATION BY BUSINESS
I certify that I am authorized by the business listed above to state that all of the information on this form is true and accurate.I
understand that if the above person does not qualify for independent contractor status,the proper premium can be assessed.
Signature Title
STATE OF COLORADO,COUNTY OF
Subscribed and sworn before me by this day of ,
Commission expires:
NOTARY PUBLIC
Page 2 of 2
ZAUCCtF007 R-02-06
AMERICA!FAMILY MUTUAL INSURANCE COMPAN"
6000 American Pkwy • Madison, WI 6376
CLAIMS:1-800-MYAMFAM(1-800-692-6326)
COLORADO MOTOR VEHICLE
PROOF OF INSURANCE CARD
Policy No: 2032-1148-02-49-FPPA-CO
Effective Date: 5-1-2014 Expiation Date: 11.1-2014
2008 DODO CXT VIN:1838848858D654962
Coverages: BIPD UM UIM ME COMP COU.
KUEWER,CHRIS&PAMELA S
10473 TAYLOR AVE
FIRESTONE CO 80504-6531
Agent Patricia Upwood
t Phone: (303)759-2356 (303)610-6171
This card must be carried in the insured motor vehicle
for production upon demand.
Important message on reverse side. ( :.
AMERICAN FAMILY MUTUAL INSURANCE COMPANY
6000 American Pkwy • Madison, WI 63783
CLAIMS:1.800MYAMFAM(1.800-692-66326)
COLORADO MOTOR VEHICLE
PROOF OF INSURANCE CARD
Policy No: 2032.1148-01.46-FPPA-CO
Effective Date: 5-1-2014 Expiration Dab: 11-1-2014
2002 DODO DPL VIN:188H858Z22F138650
Coverages: BIPD UM UIM ME COMP COLL ERS
KLJEWER,CHRIS&PAMELA S
10473 TAYLOR AVE
FIRESTONE CO 80504-8531
Agent Patricia Upwood
Agent Phone: (303)759-2355 (303)6108171
This card must be carded in the insured motor vehicle
for production upon demand.
Important message on reverse side. 'r""o.m�.,
Hello