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Home My WebLink About20153222.tiff by-A-ro.d- lbw /S8 MEMORANDUM DATE: September 25, 2015 1861� " .'" '+ TO: Board of County Commissioners—Pass-Around r '" FR: Judy A. Griego, Director, Human Services COUNTY RE: Weld County Department of Human Services' Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreement 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 Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements. These items were not entered into the Contract Management System by Child Welfare staff and for purposes of audit they now need to be approved by the Board. The boiler plate agreement form was approved by Pass- Around dated July 15, 2014, and approved by Bruce Barker.The major provisions for these Agreements are as follows: No. Provider/Term Facility Type/Location Daily Rate I Salazar, Clara and Michael County Foster Care Provider Negotiated based Greeley,CO on child needs April 28, 2015—June 30, 2015 2 Oliver, Jonathon and Melynda County Foster Care Provider Negotiated based Erie,CO on child needs May II, 2015—June 30, 2015 3 Schulz, Lindsey County Foster Care Provider Negotiated based Greeley, CO on child needs May 8, 2015 —June 30, 2015 I do not recommend a Work Session. 1 recommend approval of these agreements. Approve Request BOCC A enda Work Session Sean Conway Steve Moreno Barbara Kirkmeyer Mike Freeman Julie Cozad Pass-Around Memorandum; September 25, 2015 - Contract IDs 186-188 Page 1 6/1/0-4/" C� d5i4CAA-- 2015-3222 (1) /o 0,7 /O-0 7�/ Y{e Dael INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT IIt THIS AGREEMENT is made and entered into this ��day ofa/ti-4-100 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 Schulz, Lindsey,whose address is 5121 W. 11th St., Apt. 409,Greeley,CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS,the Colorado State Department of Human Services (hereinafter referred to as"State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must,during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services,and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from May 8,2015,to and until June 30,2015, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty(30)days prior to the intended date of termination. If notice is so given,this Agreement shall terminate upon the expiration of thirty (30)days,or until the eligible child(ren) may be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. Il. AGREEMENTS OF THE PARTIES: A. Contractor agrees: I. 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. CWS-7A Individual Provider Contract 1 Revised 8/2014 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives,and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings,and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. II. 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. CWS-7A Individual Provider Contract 2 Revised 8/2014 i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HEPAA). 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. CW'S-7A Individual Provider Contract 3 Revised 8/2014 27. To indemnify County and the State Department against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this Agreement or by conditions created thereby, or based upon any violations of any statute,ordinance, or regulation and the defense of any such claims or actions. 28. To maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, State Department, or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 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. CWS-7A Individual Provider Contract 4 Revised 8/2014 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services,the County Department and the Provider shall verify foster care placement of each child in writing on the required form,which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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 shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure CW'S-7A Individual Provider Contract 5 Revised 8/2014 the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on- site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement,where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant,and further,Contractor represents. warrants,and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: I. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,or performing a public (federal, state,or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal. state,or local) with commission of any of the offenses enumerated in paragraph (B)above. 4. Have not within a three-year period preceding this Agreement, had one or more CWS-7A Individual Provider Contract 6 Revised 8/2014 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 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. C\4'S-7A Individual Provider Contract 7 Revised 8/2014 WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. ��JJ COUNTY: W•47144)ATTEST: `�• `I'CL �BOARD OF COUNTY COMMISSIONERS Weld Clerk to the and WELD COUNTY,C LORADO By: • Deputy lerk to the d arbara Kirkmeye ,Chair CI 0 7 2015 APPROVED AS TO ING: APPROVED AS TO UBST NCE: LLr-t' 4 Controller Electe fficial o Departme Head APPROV D AS TO �J�► Director ofleneral Services County Attorney 361 � / Flt J CONTRACTOR: Schulz,Lindsey . tL1' ,�► 5121 W. 11th St.,Apt.409 Greeley,CO 80634 By . _ _ ..� /7/2015 Contrac (or design. '.)Signature and Date By: Contractor's(or designee's)Signature and Date CWS-7A Individual Provider Contract 8 Revised 8/2014 O2.0/5- 3022Q6) 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 Schulz, Lindsey, hereinafter referred to as, "Contractor." GENERAL PROVISIONS . County and Contractor agree that a child specific Needs Based Care Assessment, designated within this exhibit as Exhibit B, 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 Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees to provide the care and services,which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for the Child Maintenance level of service, as indicated by the Needs Based Care Rate Table, designated within this exhibit as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1665608. 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 9 Revised 8/2014 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. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five(5)calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s)to the Human Services' C W S-7.A Individual Provider Contract 10 Revised 8/2014 Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 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 Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 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. 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. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended,proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction; CWS-7A Individual Provider Contract 11 Revised 8/2014 violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B)above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions(federal, state,and local)terminated for cause or default. 13. 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 8/2014 EXHIBIT B 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. Pl. How often does the child require transportation by the foster care provider for the following: Select One Therapy;Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a rejular or special education plan? 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) Select One **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. T1. How often are theta, •services needed to address child's individual needs 'er 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 0 Self-injurious Behavior Select One ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One Enuresis/Encopresis Select One Runaway Select One ❑ Sexual Offenses " Select One ❑ Inappropriate Sexual Behavior k Select One ] Disruptive Behavior Select One Delinquent Behavior Select One ❑ Depressive-like Behavior Select One ❑ Medical Needs-(If condition is rated"severe",please Select One complete the Medically fragile NBC) ❑ Emancipation Select One ❑ Eating Problems _ Select One Boundary Issues Select One Requires Night Care Select One 0 Education Select One ❑ Involvement with Child's Family Select One Exhibit B to the Additional Provisions 13 Revised 6/2014 mosnou- EXHIBIT C Weld County Department of Human Service Needs Based Care Rate Table (Effective 7/01/2014) £ kr»x 4'<f P .7.? r� 4a.. y -.,'' L ,�4 f t* C �`.tE rk₹ 3,i".4, > eta" W s 1 ,x; . sz x " � 9 c ",IL . x 1;r° d t t._� i w .., B FVG P ' p,� Z. 57 '4 g ,r Y •eit e i Zb� �3 4 ^�S r7*-*04'4 4:3 i •}fiC3r. %".1"x ,N.. �� • f ', t``@ �x iti a, -; $:; .,•.:;;'•`,14'•;' • -f- . y ?ax �. . *~ .ieb• �ts —,,,'"A'.',,, .t ,14 .`.-• a .. Y,•• ,.2�. -:`,y . �.t"; _ F.• "�.... i '�1 t ..,,'j , �' . 512.14 County Basic : Age 0-10...$16 73 ',I. 5,66 a> ; No crisis intervention,Minimal $0.00 �„ Maintenance Age I I-14...$1$50 ^ Not needed or cover g CPA involvement,one face-to IN- Rate Age 15-21...519.75 - s under Medicaid. face visit with child per month. ' $15.51 ` 55.05 Minimal crisis intervention as Regularly Scheduled i . 1 $•'0.22 a 5.66 needed,one face-to-face visit ' therapy up to 4 t'•';'''', X3.39 t; per month with child.2-3 1 hours/month. contacts per month ?t Az 1 ' { $23.59 5.66 . $17.19 _ ,0 $18.88 $10.11 Occasional crisis intervention as Weekly scheduled '�± 2 526.96 $ 5.66 needed,two face-to-face visits ' therapy 5-8 hours a 54.89 1.1with child.2-3 contacts per x month with 4 hours of month a' group therapy. 2'/L F $30.33 5.66 $20.56 x �m $22.24 y Regularly scheduled ,,_.• , 3,--' t I' Ongoing crisis intervention as t'' weekly,multiple i,„,:- 3 $33.70 s $66 needed,weekly face-to-face sessions,can $6 39 11 visits with child,and intensive x i) t more than 1 person, ft: coordination of multiple services. 9-1 ' nthly ii*- 3 1 24. $3 7.06 5.66 .F $23.93 s? $25.61 ,. :; i Ongoing crisis intervention as ." 4 needed,which includes high RCCF $40.44 5.66 level of case management and '; Negotiated Drop Down * ,,, I CPA involvement with child and �, ' `. provider and 2-3 face-to face �' 4,*; ,-- contacts per week minimum. ';'. t. i� x sssS, _� � . : `,tea.,,;=4 ..°Y.�' ,x .rna � '• # .' . ^cs �- , -, h, Assessment/ i: •. Emergency #- 526.96 . 5.66 l'j'- $18.88 r Level Rate v Exhibit C to the Additional Provisions 14 Revised 6/2014 Esther Gesick From: Cecilia Moreno Sent: Monday, September 28, 2015 2:13 PM To: Esther Gesick Cc: Lesley Cobb; Jacquie Higinbotham Subject: FW: contracts See below Esther— Cecilia Moreno Employment Services Support Specialist Employment Services 315 N 11 Ave 8 Greeley, CO 80631 970-353-3800 ext. 6756 r — ! Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From:Judy Griego Sent: Monday, September 28, 2015 2:11 PM To: Cecilia Moreno Subject: RE: contracts I am okay with it as long we make a notation as to why we didn't go through the pass-around and who was involved in the decision making. Keeping the emails of this exchange would be good. Judy A. Griego, Director Weld County Department of Human Services 315 N 11th Avenue BLDG B Greeley, CO 80631-2014 970.352.1551, extension 6510 Fax 970.353.5215 griegoia pweldgov.com <image003.jpg> Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication.Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 2015-3273 1 From: Cecilia Moreno Sent: Monday, September 28, 2015 2:09 PM To:Judy Griego Cc: Esther Gesick; Lesley Cobb;Jacquie Higinbotham Subject: RE: contracts The 43 contracts in question are Foster Care Facility Agreements CWS-7A with Exhibit A. The thought process of Esther and Child Welfare is that Legal/Finance/BOCC have already reviewed the contract template and rate approvals so there is no reason to review them again now that they are filled out with provider information; thus developing a "fast-track" within the CMS. Do you have a different take on this? Cecilia Moreno Employment Services Support Specialist Employment Services 315 N 11 Ave B Greeley, CO 80631 970-353-3800 ext. 6756 tj pr Mt LRr r Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From:Judy Griego Sent: Monday, September 28, 2015 1:55 PM To: Cecilia Moreno Subject: RE: contracts If we bypass the pass-around process, I am wondering out loud what that means. I can't tell what type of contracts you are listing. Judy A. Griego, Director Weld County Department of Human Services 315 N 11th Avenue BLDG B Greeley, CO 80631-2014 970.352.1551,extension 6510 Fax 970.353.5215 griegoia Pweldgov.com <image003.jpg> Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication.Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 2 From: Cecilia Moreno Sent: Monday, September 28, 2015 1:53 PM To: Frank Haug Cc:Judy Griego; Barb Connolly; Lesley Cobb;Jacquie Higinbotham; Esther Gesick Subject: RE: contracts Frank, The contracts have actually been sitting with the originator.These are the items that Esther has deemed fast-track since the form was approved and now the signed items just need to go to consent. Frank/Barb,the contracts you can move forward without review are as follows: 192, 193, 194, 195,197, 198, 199, 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 220, 221, 222, 223, 224, 225, 226, 227, 228, 229, 230, 231, 232, 233, 234, 235, 236.Also, please note that 185, 196, 219, are still with the originator waiting for the statement of work to be uploaded but will be considered fast-track as well. Judy, I believe Esther said these can bypass pass-around as well but I am waiting for her response to be sure. Cecilia Moreno Employment Services Support Specialist Employment Services 315 N 11 Ave B Greeley, CO 80631 970-353-3800 ext. 6756 r - I, Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Frank Haug Sent: Monday, September 28, 2015 11:42 AM To: Cecilia Moreno Subject: contracts I saw several contracts had been initiated, but I don't see them on my queue,just wanted to let you know. My guess is they are with accounting or something. Frank N. Haug Assistant Weld County Attorney 1150 O Street Mailing Address: P.O. Box 758, Greeley, CO 80632 tel: (970)356-4000 x4394 fax: (970)352-0242 3 0)0n-h-cLa 'D' M EMORANDUM DATE: September 25, 2015 ,�► 861 tj r , TO: Board of County Commissioners—Pass-Around PI FR: Judy A. Griego, Director, Human Services cbuNT RE: Weld County Department of Human Services' Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreement 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 Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements. These items were not entered into the Contract Management System by Child Welfare staff and for purposes of audit they now need to be approved by the Board. The boiler plate agreement form was approved by Pass- Around dated July 15, 2014, and approved by Bruce Barker.The major provisions for these Agreements are as follows: No. Provider/Term Facility Type/Location Daily Rate 1 Salazar, Clara and Michael County Foster Care Provider Negotiated based Greeley, CO on child needs April 28, 2015 —June 30, 2015 2 Oliver, Jonathon and Melynda County Foster Care Provider Negotiated based Erie,CO on child needs i May 11, 2015—June 30, 2015 3 Schulz, Lindsey County Foster Care Provider Negotiated based Greeley, CO on child needs May 8, 2015 —June 30,2015 • I do not recommend a Work Session. I recommend approval of these agreements. Approve Request BOCC A enda Work Session Sean Conway Steve Moreno Barbara Kirkmeyer Mike Freeman Julie Cozad Pass-Around Memorandum; September 25, 2015 - Contract IDs 186-188 Page 1 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this /D day of /vl1A-Y ,20/3—, by and between the Board of County Commissioners of Weld County,on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County,"and Oliver,Jonathon and Melynda,whose address is 1114 Micros St., Erie, CO 80516, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as"State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as"Facility"), and WHEREAS, Contractor understands and agrees that it must,during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW,THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from May 11,2015,to and until June 30,2015, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty(30)days prior to the intended date of termination. If notice is so given,this Agreement shall terminate upon the expiration of thirty(30)days, or until the eligible child(ren) may be placed elsewhere, whichever occurs first,and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. 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. CWS-7A Individual Provider Contract 1 Revised 8/2014 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings,and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 11. To give the County Department two weeks notice, except in an emergency,to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. 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. CWS-7A individual Provider Contract 2 Revised 8/2014 i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex,age, religion, political beliefs, national origin,or handicap,and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical,educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. 22. To conform with and abide by all rules and regulations of the Colorado Department of Human Services,the Colorado Department of Health Care Policy and Financing(if appropriate),the State of Colorado and any applicable federal 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. CWS-7A Individual Provider Contract 3 Revised 8/2014 27. To indemnify County and the State Department against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this Agreement or by conditions created thereby,or based upon any violations of any statute,ordinance,or regulation and the defense of any such claims or actions. 28. To maintain service program records, fiscal records,documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, State Department,or County personnel,and other persons authorized in writing by the State Department Executive Director. B. County agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement,parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs,and separation/loss issues. 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. CWS-7A Individual Provider Contract 4 Revised 8/2014 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services,the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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 shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure CWS-7A Individual Provider Contract 5 Revised 8/2014 the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports,on- site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood,earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant,employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: I. Are not presently debarred,suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B)above. 4. Have not within a three-year period preceding this Agreement, had one or more CWS-7A Individual Provider Contract 6 Revised 8/2014 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 cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement,or other agreements between County and Contractor,or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five(5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s)to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 7 Revised 8/2014 WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTE : dater/WV "��//1='64.BOARD OF COUNTY COMMISSIONERS Wel u ty Clerk to the oard WE D COUNTY,COL DO By. Deput} lark to the and Barbara Kirkmeyer,C air OCT 0 7 2015 APPRO ED AS TO 1NG: APPROVED AS TO S TANCE: "...-414446ka. ... Controller E ec Official or Dep ent He APPROVED AS TO FORM: 1 I I Director of General Services County Attorney Z�� 'p` ,CONTRACTOR: t$61 ;, *1 '..,+.► '" Oliver,Jonathon and Melynda i .� 1 1114 Micros St. Erie,CO 80516 By:L May 10.2015 Contractor's(or designee's)Signature and Date ((��,, � By: f Q WbeI..May 10,2015 Con is(or designee's)Signature and Date CWS-7A Individual Provider Contract 8 Revised 8/2014 02.0/5----0020202 69- 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 Oliver,Jonathon and Melynda, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated within this exhibit as Exhibit B, 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 Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for the Child Maintenance level of service, as indicated by the Needs Based Care Rate Table,designated within this exhibit as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1665582. 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 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. CWS-7A Individual Provider Contract 9 Revised 8/2014 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. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor,or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five(5)calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or CWS-7A Individual Provider Contract 10 Revised 8/2014 administrative agency, shall deliver copies of such document(s)to the Human Services' Director. The term"litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 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 Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 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. 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. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain,or performing CWS-7A Individual Provider Contract 11 Revised 8/2014 k9'ri __"A:k3:rt. Ml, ➢'/ 14'•,/'5A'S.IM '91M "i.. '! 1MRN .may - '� •p WY16. -1" R ;is _. a public (federal, state, or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements,or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph(B)above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local)terminated for cause or default. 13. 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 8/2014 EXHIBIT B 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: Select One Therapy; Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. TI. How often are theras services needed to address child's individual needs .er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 6/2014 EXHIBIT C Weld County Department of Human Service Needs Based Care Rate Table (Effective 7/01/2014) ,1tr_.: wot t4.0 $12.14 ' 4,44 County Basic I Age 0-10...$16.73 ,t 5 $0.00 $.66 !;.:7,-.'j No crisis intervention,Minimal Maintenance - Age 11-14...$18.50 . - � Not needed or cover Age 15-21...$19 75CPA involvement,one face-to- Rate L - under Medicaid. - g ti:'--') face visit with child per month. Y fkfl ft.�E $15.51 -': $5.05 v Minimal crisis intervention as Regularly Scheduled 1 $20.22 ON $.66 needed,one face-to-face visit $3.39 t therapy up to 4 per month with child,2-3 hours/month. f contacts per month f s I 'A ....' $23.59 $.66 ., $17.19 i,::...4*,, ...8 _ $18.88 $10.11 Occasional crisis intervention as Weekly scheduled 2 ta $26.96 $.66 needed,two face-to-face visits therapy 5-8 hours a $4.89 with child,2-3 contacts per ;w month with 4 hours of 1 month -r group therapy. _a.2'A $30.33 $.66 ...fil 2, $20.56 $22.24 '' $15.16 e..„ Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 $33.70 $.66 needed,weekly face-to-face t sessions,can include $6.39 ST visits with child,and intensive O7. more than 1 person, i iiii coordination of multiplev. i.e.family therapy,for A services. 9-12 hours/monthly. 3 1/2 $37.06 $.66 g $23.93 _ $25.61 .A f,.; a _- Ongoing crisis intervention as 4 Li w needed,which includes high $.66 Icvcl of case management and _-r,- Negotiated RCCF � $40.44 , - Drop Down CPA involvement with child and I a provider and 2-3 face-to face a1 ' - contacts per week minimum. K Assessment/ t ' s Emergency $26.96 .t, $.66 .3 $18.88 Level Rate Exhibit C to the Additional Provisions 14 Revised 6/2014 1 &on twit MEMORANDUM DATE: September 25, 2015 1861 TO: Board of County Commissioners—Pass-Around -,� I L r r • FR: Judy A. Griego, Director, Human Services COUNTY RE: Weld County Department of Human Services' Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreement 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 Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements. These items were not entered into the Contract Management System by Child Welfare staff and for purposes of audit they now need to be approved by the Board. The boiler plate agreement form was approved by Pass- Around dated July 15, 2014, and approved by Bruce Barker. The major provisions for these Agreements are as follows: No. Provider/Term Facility Type/Location Daily Rate I Salazar,Clara and Michael County Foster Care Provider Negotiated based Greeley,CO on child needs April 28, 2015—June 30, 2015 2 Oliver, Jonathon and Melynda County Foster Care Provider Negotiated based Erie, CO on child needs May 11, 2015—June 30, 2015 3 Schulz, Lindsey County Foster Care Provider Negotiated based Greeley, CO on child needs May 8, 2015 —June 30,2015 I do not recommend a Work Session. I recommend approval of these agreements. Approve Request BOCC A Benda Work Session Sean Conway Steve Moreno Barbara Kirkmeyer Mike Freeman Julie Cozad Pass-Around Memorandum; September 25, 2015 -Contract IDs 186-188 Page 1 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT ✓J THIS AGREEMENT is made and entered into this / day of , 0 /�' 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 Salazar, Clara and Michael, whose address is 1269 49th Ave. Ct., Greeley, CO 80634, hereinafter referred to as. "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services(hereinafter referred to as"State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as"Facility"), and WHEREAS,Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein,County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from April 28,2015, to and until June 30, 2015,or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty(30)days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30)days,or until the eligible child(ren) may be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: I. 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. CWS-7A Individual Provider Contract I Revised 8/2014 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family' Service Plans for children in placement, including visits with their parents, siblings,and relatives,or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. I I. 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. CWS-7A Individual Provider Contract 2 Revised 8/2014 :_"'.. ,. _..i f ^:! :t, t - 4Yu✓.... Y'".r.. ... F - .. A.... "i .. - ,,. _. T. w ,yam„ i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973,and the ADA of 1990,concerning discrimination on the basis of race, color, sex,age, religion, political beliefs, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the I lealth Insurance Portability and Accountability Act(HIPAA). IS. 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 he 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. CWS-7A Individual Provider Contract 3 Revised 8/2014 27. To indemnify County and the State Department against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this Agreement or by conditions created thereby, or based upon any violations of any statute, ordinance,or regulation and the defense of any such claims or actions. 28. To maintain service program records, fiscal records,documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, State Department. or County personnel, and other persons authorized in writing by the State Department Executive Director. B. County agrees: I. 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. CWS-7A Individual Provider Contract 4 Revised 8/2014 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 111. 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 it; 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 shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure CWS-7A Individual Provider Contract 5 Revised 8/2014 • the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports,on- site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires,strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: I. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain, or performing a public(federal, state, or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery. bribery, falsification or destruction of records, making false statements,or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more CWS-7A Individual Provider Contract 6 Revised 8/2014 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: I. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement, or other agreements between County and Contractor,or as a debt to County, or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within live(5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the County Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. CWS-7A Individual Provider Contract 7 Revised 8/2014 WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. L COUNTY: ATTE : .JC,16,16•C BOARD OF COUNTY COMMISSIONERS Weld un Clerk to the Boaid W D COUNTY,CO ORADO By: t-- Deputy C rk to the Boar Barbara Kirkmeyer,Chair OCT 0 7 2015 APPROVED AS TO FUNDING: APPROVED AS T SUB ANCE: Controller Elec Official r Depart t Head APPROVED AS TO F irector of General Services County Attorney ONTRACTOR: Salazar,Clara and Michael 1269 49th Ave.Ct. Greeley,CO 80634 By: 4 7/2015 Contrac r si e's)Signature and Date By: 4/27/24115 Contractor's(or designee's)Signature and Date CWS-7A Individual Provider Contract 8 Revised 8/2014 020/5---3c"- "ca(3) 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 Salazar,Clara and Michael. hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated within this exhibit as Exhibit B, 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 Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Contractor agrees to provide the care and services,which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for the Child Maintenance level of service, as indicated by the Needs Based Care Rate Table,designated within this exhibit as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 1663774. 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 9 Revised 8.`2014 rY No—'.."`WY d+ A.': 'M."c, ./"NI r ' r ,:IOW 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. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed: B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment due to omission,error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five(5)calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or CWS-7A Individual Provider Contract 10 Revised 8/2014 • administrative agency, shall deliver copies of such document(s)to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and'or foreclosure. CONTRACTOR SHALL: I. 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 Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 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. 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. I0. Maintain/update medication logs on a daily basis, if child is taking medications. II. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment,and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,or performing CWS-7A Individual Provider Contract I I Revised 812014 • a public (federal, state, or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph(B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions(federal, state, and local)terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VB and the Weld County Department of Human Services Policy and Procedure manual. CWS-7A Individual Provider Contract 12 Revised 8/2014 EXHIBIT B 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: Select One Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? P4. How often does the child require special and extensive involvement by the provider in scheduling i 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 j 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) Select One **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. T1. How often are thera. services needed to address child's individual needs ter 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 672014 EXHIBIT C Weld County Department of Human Service Needs Based Care Rate Table (Effective 7/01/2014) y' 4 rtart' i . AD.M �„�{ ,1. II: '1,X; #,1;40` x ifs i l A.d #�a t 7 x �c w '1 far B9 ;, - u p-r,h 4 40'1fP ,' •t'C '(� ''')''9. `'' -r,!', !',,,'1"a �, s. a1--.'* a *" sr4 g ! -acv a 1�� n nu r � �Y sue- � 'a '� k'�7 r «sLevel '''',' "V`',- , „y--7" Dc �y�t '- -, /,'.4--,----'-'-''V4,', r . ; ._des s,i c D�iw ',IF!: $12.14 County Basic Age 0-10...$16.73 , „ 1 $0.00 $.66 No crisis intervention,Minimal Maintenance Age I 1-14...$18.50 CPA involvement,one face-to- Not needed or cover Rate ^^. Age 15-21...$19.75 = under Medicaid. ,'.:, face visit with child per month. - $15.51 $5.05 Minimal crisis intervention as Regularly Scheduled 1 $20.22 $.66 needed,one face-to-face visit -y therapy up to 4 $3.39 per month with child.2-3 hours/month. contacts per month I ''A $23.59 �� $.66 $17.19 $18.88 -{ $10.11 tict '' Occasional crisis intervention as Weekly scheduled 2 $26.96 $.66 needed,two face-to-fact visits therapy 5-8 hours a $4.89 with child,2-3 contacts per month with 4 hours of ^' month group therapy. 2'/2 $30.33 a'' $.66 $20.56 s t ' $22.24 $15.16 - .fig' 0,,', Regularly scheduled (,,., Ongoing crisis intervention as weekly, multiple 3 $33.70 $.66 needed,weekly face-to-face sessions,can include $6.39 visits with child,and intensive apW more than 1 person, coordination of multiple i.e.family therapy,for services. .,�; 9-12 hours/monthly. 31/2 $37.06 $.66 $23.93 $25.61 , '- Ongoing crisis intervention as 4 =- needed,which includes high RCCF 11„ $40.44' $.66 - level of case management and �• �k Negotiated Drop Down dµµ - CPA involvement with child and �� ` provider and 2-3 face-to face contacts per week minimum.1 " u Al,"''y r 0 q q ''' '' —r ,,u N,.a.. t. t, '1.'''',4*,,''' yr�.+'7 k ',. Assessment/ *'` ' Emergency $26.96 $.66 $18.88 Level Rate 1'.r Exhibit C to the Additional Provisions 14 Revised 6/2014 /J' 9 MEMORANDUM DATE: September 25, 2015 186 ,,, TO: Board of County Commissioners—Pass-Around r t' • • FR: Judy A.Griego, Director, Human Services ` 2_ c N T Y G.O_ RE: Weld County Department of Human Services' Agreement to Purchase Out-of-Home Placement Services Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Agreement to Purchase Out-of-Home Placement Services.These items were not entered into the Contract Management System by Child Welfare staff and for purposes of audit they now need to be approved by the Board. The boiler plate agreement form was approved by Pass-Around dated July 15, 2014, and approved by Bruce Barker. The major provisions of this agreement are as follows: No. Facility Name/Term Facility Type/Location Daily Rate 1 Nightlight Christian Adoptions Child Placement Agency Services Negotiated October 28, 2014—June 30, 2015 Loveland,Colorado based on child needs I do not recommend a Work Session. I recommend approval of this agreement. Approve Request BOCC enda Work Session Sean Conway Steve Moreno Barbara Kirkmeyer Mike Freeman Julie Cozad Pass-Around Memorandum; September 25, 2015 -Contract ID 189 Page 1 //INC 020 ‘30222c2 /D- b7- /5 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A El CHILD PLACEMENT AGENCY SERVICES(CPA) ❑ CHILDREN'S HABILITATION RESIDENTIAL PROGRAM(CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY(PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY(RCCF) El RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE(RCCF) ❑ OTHER: THIS AGREEMENT is made and entered into this 5 day o P t L ,20 /5, 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 758,hereinafter referred to as,"County,"and Nightlight Christian Adoptions,whose address is 150 E. 29th Street, Loveland,CO 80538,hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services, hereinafter referred to as, "State Department,"is authorized to provide human services to individuals and families through county departments of human services, and WHEREAS,County is authorized to purchase certain services for eligible children under State Department rules,and WHEREAS, County wishes to provide these services by purchasing them from Contractor,and WHEREAS, Contractor is licensed as a Child Placement Agency,Residential Child Care Facility,certified Psychiatric Residential Treatment Facility,or meets the requirements for other licensed service types. NOW,THEREFORE, in consideration of the mutual promises and covenants made herein,County and Contractor agree as follows: I. TERM: SS-23A Revised 8/2014 1 4k 4, _. ..Ad 9. 9: _,_\M' Y`, . OWN *Pi /. �„... Ay ,4 ,Vw' "Y+' MW f'. z .'M...'�'Ai-tY+^A �,trt P.- ....,i.. v x.- A. The term of this Agreement shall be from October 28,2014,to and until June 30, 2015. 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 children)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. SERVICES TO BE PROVIDED BY AND REOUIREIMIENTS OF CONTRACTOR: A. Services to be provided by Contractor are detailed herein in the document entitled, "Additional Provisions,"which is attached hereto and referred to herein as "Exhibit A." B. County and Contractor agree and understand that the reasons for referral,which necessitate purchasing services for children,are specified in the Child Specific Addendum(SS23B)and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the Child Specific Addendum(SS23B). C. County and Contractor shall develop an Initial Individual Plan of Care that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes,except PRTF. County and Contractor shall formulate an Individual Plan of Care within 14 calendar days after admission for children in RCCFs or group homes,except PRTF. The placement date is that date noted in Child Specific Addendum(SS23B). Modifications to the Individual Plan of Care must be agreed to in writing. D. County and Contractor shall formulate an Initial Individual Plan of Care for children in PRTFs within 72 hours. For children in a PRTF, a comprehensive Individual Plan of Care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the Child Specific Addendum(SS23B). Modifications to the Individual Plan of Care must be agreed to in writing. E. The Individual Plan of Care shall be goal oriented and time-limited and shall: 1. Address all areas listed in Section 7.714.4,C,2,(12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health,emotional status, behavior,support system in the community, available resources, and discharge plan. SS-23A Revised 8/2014 2 2. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. 3. Specify the type, frequency,and duration of clinical therapy services, rehabilitation services,medication management,emergency services,initial assessment,documented treatment modifications,and other services determined to be necessary to meet the child's specific goals. 4. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. 5. Identify the provision of,or the referral for,services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. 6. Specify the anticipated living arrangement for the child at the date of discharge. 7. Specify the anticipated educational arrangement for the child at the time of discharge. 8. Specify the anticipated date for discharge from treatment purchased for the child. 9. Specify a permanency goal for the child. F. Monthly,Child Placement Agencies, RCCFs and all other Contractors,other than PRTF, shall conduct a monthly review of each Individual Plan of Care to evaluate whether the short-term and long-term goals have been achieved or not achieved. These Contractors shall provide County with written reports which address changes to the child's physical condition,psychological and social functioning,changes in the child's family situation, educational progress, significant incidents or disciplinary actions,and progress made to achieve goals specified in the treatment plan. Further, Contractor agrees to sequence reports to be received by County fifteen(15)calendar days prior to judicial or administrative hearings or reviews when provided with thirty (30)calendar days advance notice of such review dates by County. G. Every fourteen(14)days, PRTFs shall provide County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions,and progress made to achieve goals specified in the Individual Plan of Care. H. Contractor shall: I. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and SS-23A Revised 8/2014 3 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. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. 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. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964,Section 504 of the Rehabilitation Act of 1973,Title XX of the Social Security Act of 1975 as revised,and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain at all times during the term of this Agreement a liability insurance policy of at least$25,000 for CPAs($400,000 for PRTFs and RCCFs) for property damage liability, $150,000 for injury and/or damage to any one person, and$600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 7. Maintain during the terms of this Agreement a fidelity bond of at least$25,000 or two (2)months gross receipts, whichever is greater,covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this Agreement in order to make reparations for any wrongful acts,omissions, or any other defalcations of Contractor. 8. Indemnify County,the Colorado Department of Human Services, Colorado Department of Health Care Policy&Financing,and the State of Colorado, 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. (Paragraphs 6,7 and 8 do not apply to agreements between County and the University of Colorado.) 9. In regards to University of Colorado Contractors only,Contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the SS-23A Revised 8/2014 4 full extent allowed by law. Notwithstanding the foregoing,nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in§24-10-101 to §24-10-120,C.R.S.,any claims resulting from the performance of the University of Colorado,its employees or agents under this Agreement. 10.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,Colorado Department of Human Services,Colorado Department of Health Care Policy& Financing,or county personnel,and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. In any instance of a potential adoption by a foster parent,provide the initial home study,the SAFE study update,annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and Contractor, during regular business hours. 12.Invoice the County for services rendered,using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for-service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate,CPAs and other Contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within thirty(30)calendar days following the billing due date. 13. Attend and participate in Administrative Reviews for children in placement with Contractor pursuant to two(2)weeks written notice by the County. Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14.Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. I. Audit and financial requirements. The purpose of these requirements is to provide minimum assurance that Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to County and to the State of Colorado Department of Human Services for the use of public funds. SS-23A Revised 8/2014 5 1. Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements,prepared from information provided by this system,shall be presented in conformity with U.S. generally accepted accounting principles(GAAP). Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of Contractor shall be subject,at any reasonable time, to inspection,audit or copying by appropriate Federal, State or county personnel,or such independent auditors or accountants as may be designated by these personnel. 2. All billing by Contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month,on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. 3. All Contractors whose total annual expenditures are$100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than$100,000 may submit an audit as described above or may submit compiled or reviewed financial statements,prepared in accordance with generally accepted accounting principles. If Contractor is a government agency that has an independent audit done by another agency of that government,its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited,compiled or reviewed financial statements of PRTFs,RCCFs,and CPAs must be completed and a copy provided to the Colorado Department of Human Services(Attn: Administrator for PRTFs,and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after Contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B(1),above and must contain sufficient detail to provide evidence of financial accountability under the terms of this Agreement and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable,Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget(OMB)Circular A-133,Audits of States,Local Governments,and Non- Profit Organizations including subsequent revisions,and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. 4. If Contractor does not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal SS-23A Revised 8/2014 6 Agent may withhold payment until the audit and/or requested information is submitted. If Contractor is a CPA, then sanctions of Contractor may occur for failure to submit. 5. In cases where documentation does not exist to support audit information or services provided,Contractor will be required to repay all funds received for which documentation does not exist. 6. hi cases where audit deficiencies are noted,a plan of corrective action shall be submitted to the State Department's Audit Division for approval within four(4) months of the date of the audit. 7. Failure to comply with any of these requirements,including items on the addendum is justification for the County to impose possible fiscal sanctions, penalties,or cancel the Agreement. III. PAYMENT TO CONTRACTOR: A. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. Any child may be removed from the facility prior to the end of the term by County. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. B. Payment for a child's temporary absence from the facility, including absence due to hospitalization,will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1,F (12 CCR 2509-5). C. All invoices from contractor shall be submitted to and approved by the appropriate County staff. Payment for placement services shall be paid from the date of admission up to,but not including,the day of discharge. Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this Agreement and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway"status unless the County has previously approved it. Invoices for therapy costs for clients enrolled in PRTF, RCCF,and CHRP programs shall be submitted to the Medicaid Fiscal Agent in SS-23A Revised 8/2014 7 accordance with instructions provided by such Fiscal Agent. Contractor shall forward copies of such billings to the County on a monthly basis. D. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, Contractor shall refund those dollars forthwith. E. In the event this Agreement is terminated,final payment to Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to Contractor due to omission,error,fraud,or misuse of funds shall be recovered from Contractor either by deduction from subsequent payments under this Agreement or other Agreements between the County and Contractor or by the County,as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this Agreement or appropriate statutes and regulations. F. If this Agreement covers an initial placement for a child,Contractor may receive a clothing allowance in accordance with State Department rules. G. Reimbursement rates that are negotiated between the County and Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services,administrative maintenance, and treatment.Contractor type will determine which of these four components will be included in the reimbursement rate. IV. TRANSPORTATION: A. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from Contractor's facility, County shall provide transportation to either return the child to the facility or to other care as arranged by County. County has responsibility for the decision to return the child to the facility, with input from Contractor. B. All other transportation associated with Contractor's proposed services shall be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However,provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. C. Any transportation costs to be incurred on behalf of a child in placement,which are to be borne by persons,or agencies,which are not a party to this Agreement,shall be specified in the treatment/service plan,and those persons shall acknowledge their responsibility by signing the treatment/service plan. SS-23A Revised 3/20(4 8 ,.. i !"Jl ®a► "" ..b..`. x "ti` .:".fa- K.iV■"'"""`7i` _...,, ,.. ,,,. .. m ,, „`. .� .»._ ,.�„ -«. _.sY-W�..�ewa: xw xr.✓ D. Transportation may include,but is not limited to;visitation with family members, medical/dental or mental health appointments, extracurricular activities, court hearings or other specialized programming. Transportation expectations will be documented on the Child Specific Addendum,SS23B. V. LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to Contractor to authorize routine or emergency medical and dental treatment,except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. b. It is mutually understood hereto that hospital expenses,surgery,ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. c. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren)is enrolled in the Early and Periodic Screening,Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren)to participate in planned recreational and social activities of Contractor,including supervised off grounds excursions and extended trips within the State,provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7)days within a consecutive 30-day period. Such written permission may be in the treatment/service plan. Further,Contractor and County will also secure,where possible,permission from parents or guardians of the child placed with Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. 5. Contact by Contractor with County regarding emergency medical, surgical or dental care will be made in person-to-person communication,not through phone mail messages. During regular work hours,Contractor will make every effort to notify the assigned caseworker, supervisor,or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours,weekends and holidays,Contractor will contact the Emergency Duty Worker at the pager number(970) 304-2749. SS-23A Revised 8/2014 9 VI. RESPONSIBILITIES OF COUNTY: A. County shall: 1. Determine eligibility of the children under this Agreement for placement and medical coverage.Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10(above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado,any of which may be amended from time to time. 5. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 6. Invite Contractor to administrative reviews at least two (2) weeks prior to the scheduled review. 7. Involve Contractor in planning for the child and give Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 8. Seek recovery from the RCCF,CPA or other Contractor type for any non- Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other Contractor type. The County shall seek recovery of any remaining funds as a debt due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 9. Identify the amount agreed upon with Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. SS-23A Revised 8/2014 10 VII. 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, the SS23B, 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, the SS23B,and the Needs Based Care Addendum in writing, if agreed to by both parties. This Agreement,Exhibit A, the SS23B,and the Needs Based Care Addendum are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. SS-23A Revised 8/2014 1 I .40."Wit ., YV ... t►�a ` �.. ., _.. G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement,where such failure is due to any cause beyond its reasonable control,including but not limited to Acts of God,fires,strikes,war, flood,earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies,procedures,and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant,and further, Contractor represents,warrants,and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant,employs illegal aliens or subcontracts with illegal aliens,County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred,suspended,proposed for debarment,and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not,within a three-year period of preceding this Agreement,been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain,or performing a public(federal, state,or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft,forgery,bribery, falsification or destruction of records,making false statements,or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal,state,or local) with commission of any of the offenses enumerated in paragraph(B) above. 4. Have not within a three-year period preceding this Agreement,had one or more public transactions(federal, state,and local) terminated for cause or default. SS-23A Revised 8/2014 12 N. In addition to terminating this Agreement, in accordance with the provisions of Section I.,above,County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement, Exhibit A, the SS23B,and 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: I. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor cannot be performed or if performed would be of no value to County. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to County. 3. Recover from Contractor any incorrect payment to Contractor due to omission, error,fraud,and/or defalcation by deducting from subsequent payments under this Agreement,or other agreements between County and Contractor,or as a debt to County,or otherwise as provided by law. O. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement,and all rights of action relating to such enforcement,shall be strictly reserved to the undersigned parties or their assignees,and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may possess,nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. Q. Contractor shall promptly notify County in the event in which it is a party defendant or respondent in a case,which involves services provided under the agreement. The Contractor,within five(5) calendar days after being served with a summons, complaint,or other pleading which has been filed in any federal or state court or administrative agency,shall deliver copies of such document(s)to the County Director. The term"litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. SS-23A Revised 8/2014 13 r N' ter., y � vr vrwA k r �.". w ._ _ r Wit r e WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. dgIreA4/0 00UNTY: ATTES : v• X146;ABOARD OF COUNTY COMMISSIONERS Weld •o n Clerk to the :o- d WELD COUNTY,CO ORADO / By: I . �.� /451A,40.1.— (-- s eputy C r rk to the Bo Barbara K' kmeyer Chair D S Tr, i ,s� l /� • OCT 0 7 2015 AP� � PROVED AS TO S :ST CE:rte' '�'=•�= �1 ,� Controller t86t t; �?`c F�1 to. •fficial or epartmen a ead APPROVED AS TO ` c %% .j✓"r Director of General Services County Attorney CONTRACTOR: Nightlight Christian Adoptions I50 E.29th Street Love! d,CO 80538 ontractor's(or esign igna e and Date SS-23A Revised 8/2014 14 EXHIBIT A to the SS23A Additional Provisions for the Agreement to Purchase Out-of-Home Placement Services SS23A For the Purchase of Child Placement Agency Services The following additional provisions apply to the agreement entitled, "Agreement to Purchase Out-of-Home Placement Services SS23A,by and between the Board of County Commissioners of Weld County,on behalf of the Weld County Department of Human Services,"hereinafter referred to as,"County,"and Nightlight Christian Adoptions,hereinafter referred to as, "Contractor." 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated in this exhibit as Exhibit B,shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a certified kinship foster care home or a foster/adoption home as a pre-adoptive placement. 2. County agrees to purchase and Contractor agrees to provide the care and services,which are listed in this Agreement,based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service,as indicated by the Needs Based Care Rate Table,designated in this exhibit as Exhibit C, for children placed within the CPA identified as Provider ID#1590226. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level for Child Maintenance as indicated within Exhibit C. 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. For Children's Habilitation Residential Program(CHRP)waiver eligible children, County agrees to pay the federal SSI rate to Contractor and all other service costs will be billable under the CHRP program. 4. 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 County's Department Administrator before payment will be release to provider. 5. A minimum of one polygraph test per Colorado fiscal year, if needed by the child,will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 6. Any additional costs for specialized services,which include,but are not limited to; polygraph tests,plethysmographs,and urinalysis screens,which are not provided within the negotiated provider rate, will need to be authorized,in writing by County,prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 7. Contractor agrees to have appropriate personnel available to attend or participate in Family Engagement or Team Decision making meetings. Contractor shall.be notified by County staff of the dates and times attendance is requested. Exhibit A to the SS23A 1 Revised 8/2014 8. Contractor agrees to cooperate with any vendors hired by County to shorten the duration of placement. 9. Contractor agrees to 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 shall be forward to County. 10. Contractor agrees to arrange a full evaluation of an Individualized Educational Plan(IEP) for youth designated as a Special Education Student every 3 years and coordinate reviews every year. If the IEP is due while the child is in placement, the Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Children in Psychiatric Residential Treatment Facilities,Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. Exhibit A to the SS23A 2 Revised 8/2014 Wwto—ro'fi.~a4..V,r VOA t®'va.Ak"A A:.N. ,...a.... A EXHIBIT B 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: Select One Therapy;Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T4. How often are therapy services needed to address child's individual needs ler 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 Exhibit A to the SS23A 3 Revised 6/2014 EXHIBIT B WELD COUNTY DHS Requested Services from Agency Please indicate the services that are requested for this child. The following information will be reflected on the child specific contract. (Please be specific) ❑ Adoption Services 0 Medical Services O Other: NA ❑ Doctor/Dentist Appointment Coordination ❑ Provider agrees to work with family ❑ Medication Evaluation(not covered under fee for service) ❑ Therapeutic Services funded through Medicaid Fee for ❑ Medication Monitoring Service: (TRCCF) ❑ Individual Therapy ❑ Nursing Services/Coordination ❑ Group Therapy ❑ Physician Services/Coordination ❑ Interactive Group Therapy ❑ Occupational Therapy ❑ Family Therapy ❑ Speech Therapy ❑ Psychological Testing El Child Find El Pharmacological Management ❑ Other: ❑ Treatment not funded by Medicaid Fee for Service: ❑ Education: O Home Based Intervention ❑ On-Grounds School El MST Multi-Systemic Therapy ❑ Coordinate Assessment for Special Education ❑ Offense Specific Treatment 0 Public School Attendance ❑ Occupational Therapy ❑ Drug and Alcohol Treatment ❑ Speech Therapy ❑ Attend Special Education Meetings ❑ Urine Analysis/Drug Screening/Breathalyzer ❑ Other: ❑ Sexual Abuse Victimization Treatment ❑ Visitation Coordination O Independent Living Skills Training ❑ Monitor phone calls and correspondence ❑ Anger Management El Transportation for family/parent/child visits ❑ Behavior Modification Services ❑ Other: O Behavioral Assessment 0 Other: O Recreation Services El Interpreter Services O Case Management ❑ Other: ❑ Attend Court Hearings ❑ Transportation: To include: ❑ Other: Levels of Care: Provider Level: Case Management Level: Therapy Level: Date Staffed: Participants: Comments: Exhibit A to the SS23A 4 Revised 6/2014 EXHIBIT C Weld County Department of Human Service Needs Based Care Rate Table (Effective 7/01/2014) -,0-,,,,,-----% -- ----c.✓ v�---4,,,,,,,:*--*,-- ,. "x'` ,.*A \-- rteA , ^a4$),%, ,v ,`�v �,, ..•:.,,,V ti a , ' ? �' ; ^.5-- N_- `'r ...,, , f.,r. C.,'=y" ,;,- ,▪,,,,,,.,,,,,,...v...,,,,,,,,„4-,,,,,,,,,-,,, �r{,^ Ity" ; .::<J y^-,x '^�v,.lcA✓3 ^,.�,-,,?..� -,--v,..,..." ,--.-..4-.fy.A ...0'''''''y'; -e C „1l Rate "J"'x y t s�,l'. .:,, ~ �;: • Alta.,- t �teeL b---,,,',,,,,,-.0,-,:,,y "', mA - 'tir'x ,ail. e .>'2,.w ! --1 ' ,-.^, a s'`ri` "`"" ,� r a,�.a"x"v`Nxri .., • �." 4 6 -`'""' ,mow.:4 ,,z -, �`- "- �.s.`.r ',�, ` ^ ,�M N -0 County Basic Age 0-10...S16.73 v ,Rz $12'14 ter: 50.00 5.66 No crisis intervention,Minimal Maintenance ▪ Age I t-14...S 18 50 ,-..7,,,, µ Not needed or cover CPA involvement,one face-to- Rate • Age 15-21...S 19 75 u under Medicaid. ▪ ;, face visit with child per month. 7 ; S 15.51 r $s.as } Minimal crisis intervention as Regularly Scheduled 1 S20.22 r-,&'-f-5.66 needed,one face-to-face visit • S3.39 ,,„ therapy up to 4 per month with child,2-3 hours/month. s �i.`y- contacts per monthO1 a 1 1/2 • $23.59 $.66 r< S 17.19 - $18.88 S10.11 .v Occasional crisis intervention as Weekly scheduled 2 G $26.96 5.66 needed,two face-to-face visits v therapy 5-8 hours a S4.89 ,,w. r sue: with child,2-3 contacts per month with 4 hours of 41, month group therapy. 5 2'/z 530.33 e7fy 5.6611 $20.56 f v. $22.24 ,. S15.16 r w Regularly scheduled fin r: Ongoing crisis intervention as ,'4-„,t- A"' weekly,multiple 3 �`r $33.70 ▪ S.66 ,, needed,weekly face-to-face • sessions,can include -4 $6.39 s PA visits with child,and intensive • more than l person, , coordination of multiple i.e,family therapy,for , services. 9-12 hours/monthly. 31/2 ''',4.42 S37.06 S.66 r S23.93 lr Y $25.61 Ongoing crisis intervention as r 4 needed,which includes high , RCCF $40.44 S.66 level of case management and Negotiated Drop Down . E CPA involvement with child and '' -' provider and 2-3 face-to face contacts per week minimum, ,'.1'7''',';'.1:,'":' Assessment/ Emergency S26.96 `,, S.66 518.88 Level Rate Exhibit A to the SS23A 5 Revised 6/2014 CU, /991' INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 14 day of (li(' A .c� , 20/O , by and between the Board of County Commission of Weld County, on behalf of the Weld County Y Department of Human Services, whose address is P.O. Box A, Greeley,CO, 80632, hereinafter referred to as, "County," and Aughe, Nancy and Christopher, whose address is 3925 Stampede Dr., Evans, CO 80620, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESS ETII: 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 he obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to he 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: I. TERM: A. The term of this Agreement shall be from July 1, 2015, 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 chitd(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. ll d&i - 020/ -302a2 ( ) CWS-7A Individual Provider Contract 1 / Revised 6/2015 ..._ �- .wstiai.9P:._v:.r V`:W, _ ww_s.. .r' 9F�.N' va .,w'V._."� "e.. �.. . ,....w^PA AFk„ VF: P;➢Fwary w:�.e ,.�....d r n �.. 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 6/201 5 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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 .. ....... ...... ...,,� .,...,,... .. ,.. ....:..`""IY ..._. 'r .e'u.,,, ..... .LL......�....., � .: ._.... ...ry. � .._.., A •9,'8.S M-'S'd >.tiW `v.4...._. R:3' .. 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. I lave 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. 0. ft 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. d t , COUNTY: ATTEST: i+4/1/ �• '(1 BOARD OF COUNTY COMMISSIONERS Weld unty Clerk to th Board WELD COUNTY, C LORADO By: Deputy lerk to th oard arbara Kirkmeyer, Chair OCT 0 7 2015 APPROVED AS TO S + ��+•.dka, El :ed Official or D: `' •�� 1 ' CONTRACTOR: Aughe,Nancy and Christopher 3925 Stampede Dr. Evans, CO 80620 By: 6.r.400 Contra or deli e' Signature and e By Con ctor's(or desig#e' ignature an ate cA0/5 30202c=2 CWS-7A Individual Provider Contract 9 Revised 6/2015 i 1 �' 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 Aughe, Nancy and Christopher, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1539167. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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 1 l 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. 11. 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. Pl. How often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment;Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. Flow often is the foster care provider required to participate in child's therapy or counseling I Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? '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. I low 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) Select One **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. T1. How often are thera► services needed to address child's individual needs .er NBC assessment? Select One NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment J Assessment Areas: Comment: ' Rating: ❑ Aggression/Cruelty to Animals Select One _❑ Verbal or Physical Threatening Select One ❑ Destructive of Property/Fire Setting _ Select One ❑ I Stealing Select One ❑ Self-injurious Behavior Select One ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One _ ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ Emancipation Select One Eatin Problems Select One ❑ t• •ary Issues Select One _ ❑ Requires Night Care Select One _ ❑ Education Select One ❑ 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) ,14-11%--,:::::1-i';'',','::',, . 4".'''...11.V.54:,g�-4,,,, ,,`� N --ate`'�� :,: ! ' $�,as ' , ,� .4.i71s y ;s d . t x� .„.xi - ,., aE x 13 - t . . 4-r A 7 t 4 �[ i x Eddassay .lx 9t4' r9 l q� t4.4,.-4V -,-.:',AZ, '„„:-:5� { :"". s' ._-.�>< ,r*a !)se•`t F p '.,`.�..' s' }31 � .`a E 4-'1i'9,' :.' r ,kFa �' aa.* County Basic Age 0-10...$17.01 _ $12.35 s $0.00 Maintenance t. $.66 No crisis intervention,Minimal Age 11-14...$18.81 "` Not needed or cover CPA involvement,one face-to- :14:4t.. Rate Age 15-21...$20.09 z 1, under Medicaid. face visit with child per month. $15.77 $5.14 Minimal crisis intervention as " Regularly Scheduled '' 1 $20.56 ' $.66 needed.one face-to-face visit " $3.45 pY thera a P to 4 per month with child.2-3 hours/month. `- contacts per month c v : I '/: $23.99 $.66 • $17.48 4tl'` �� " $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 2 $27.42 $66 needed,two face-to face visits therapy 5-8 hours a $4.97 with child,2-3 contacts per , month with 4 hours of month '` group therapy. 'a i f 1 _- 2 '/: $30.85 ...iv:, $66 $20.91 I $22.62 r $15.42 Regularly scheduled x; 3▪≥ ,; Ongoing crisis intervention as t; weekly, multiple .` ' needed,weekly face-to-face -1 3 $34.27 $.66 sessions,can include $6.50 visits with child,and intensive 5,11... more than I person, coordination of multiple `: i.e. family therapy. for lr,' services. 9-12 hours/monthly. �3 1/2 v $37.69 g $.66 $24.34 . $26.05 fFa 4 Ongoing crisis intervention as „ Congregate ,� needed,which includes high zh $41 I3 $.66 level of case management and Negotiated Negotiated Drop Down CPA involvement with child and provider •.and 2-3 face-to face ,il :' ; contacts per week minimum. r, : ,{" n '' 3 .Y:_.4` ° 1 ;; .;'Y',, 1a'. ,.r.T ,- w x"';•='4'k,s ' - 'V. :l �h Fitt �7 ,:. ,, 4#�'' 44-A L�'. .. � },. n A f4[.,. �'X,'�5; - 1T�3#l�..�.a,:k�'�� qtr+ Assessment, Emergency *- $27.42 ' _ $.66 $19.20 �± ▪, „fi...> Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 t7) 4 /9 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 1" day of L , 20 ,by and between the Board of County Commissioneisof 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 Briseno,Joy & Briseno Jimenez, Ramon,whose address is 1124 8th St., Apt. 1,Greeley CO 80631, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015,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: I. 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. C&: I 5�C'A U 02015-�3aa,�(Co) CWS-7A Individual Provider Contract Revised 6/2015 /b -7- 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 6/20 IS 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 r... _ u.�.. ,.... VI*1SL .�:r 9..y w(Y! -*ii - `I.-4..'yam ""`.AV A. -.,aO'AO"...,. NFf. 'II..l, ...#M,...., Wy..a ,. .; . 1 I. 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. §8-17.5-102(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 612015 X. .1P * —*OM\ .,to b"A._.._._, **,.... V! 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 v _ — o u WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above, COUNTY: ddrA64.) ATTEST: '� BOARD OF COUNTY COMMISSIONERS Weld )unty Clerk to th Board WELD COUNTY, CO ORADO By: Deputy Clerk to the and arbara Kirkmeyer, Chair OT 0 7 2015 APPROVED AS TO SAS" � , �,: L.4) E ted Offi• al or Depa NTRACTOR: Briseno,Joy & Briseno Jimenez,Ramon 1124 8th St.,Apt. I Greeley, CO 80631 By: (G','/�'t�c�t�c 8/''/f,� ontractor's(or designee's) Signature and Date By. 72_4,44,41 WV! r Contractor's (or designee's) Signature and Date i LSr„c5) ) Imo` 5 /1-,x W174- /1 CWS-7A Individual Provider Contract 9 Revised 6/2015 c2 /5322,2c,2 (6') VAS ..__.... . -,.9 ,. .. -.-may-�,..Y'.. .avrw:c M .wty"` fm._eP' �.a- s' �. M"' -<.YKt Y. =y y.. „ ...., ...x ®. ..:�+► . .�.o4Npad aav nay:. ..«... 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 Briseno,Joy & Briseno Jimenez, Ramon, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1661083. 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 �rxge6400.p.ie 'V +# .. R 'rdrnmom ,tea.. .. «, «., .....,., 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 I luman 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. 11. 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 ;v≥r.Ma4a'k^'d sri+3m.Me' sF' an%`F.ihFPo'tYY"^'xbY, ., 3 . 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: Select One Therapy; Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special edu .tion elan? 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) Select One **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. T1. How often are there, services needed to address it individual needs e 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 • Substance Abuse Select One Presence of Psychiatric Symptoms/Conditions Select One ■ Enuresis/Encopresis Select One 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 Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 6/2014 PAMA* 0VO W i Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) LEV>1'OF WEI D ,-11)iAllNtS I RVI IN E I ADMINISTRATIVE MEDICAL RF,SPl fi: i SERVICE NIAIN fl \1NCE MAINTENANCE SERVICES NEEDS 1 * • r .i. Dail} Rate 1)aii� Rate I),til Rate ... Daily., „y..y D ;e $12.35 $0.00 County Basic Age 0-10...$17.01 $,66 No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover CPA involvement,one face-to- under Medicaid. Rate Age 15-21...$20.09 face visit with child per month. $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled I $20.56 $•66 needed,one face-to-face visit $3.45 therapy up to 4 per month with child,2-3 hours/month. contacts per month 1 '/2 $23.99 $.66 $17.48 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled '- ss' }-' $•66 needed,two face-to-face visits therapy 5-8 hours a $4.97 s with child,2-3 contacts per month with 4 hours of month group therapy. 2'/: :; $.66 $20.91 $22.62 $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 $34.27 $,66 needed,weekly face-to-face sessions,can include $6.50 visits with child,and intensive more than 1 person, coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. 3 1/2 $37.69 $.66 $24.34 $26.05 Ongoing crisis intervention as 4 ' needed,which includes high Congregate $41.13 $.66Negotiated Care Negotiated level of case management and CPA involvement with child and Drop Down provider and 2-3 face-to face contacts per week minimum. Assessment- ate' Emergency .'- t' $.66 $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AG EMENT THIS AGREEMENT is made this T day of , 20/J , 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 Brown, Rachel, whose address is 2809 W E. Street, Greeley, CO 80631, 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 July 1,2015, 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: I. 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. Cc; ds G,A ,24 A5---(3020202(1) CWS-7A Individual Provider Contract 1 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: I. 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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 shalt 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 612015 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. §8-17.5-102(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 6/20!5 • 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 Ibr 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. 0. 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. Cam( COUNTY: ATTEST: dj„ J 4• 'ti BOARD OF COUNTY COMMISSIONERS Weld u y Clerk to the Board WELD COUNTY, CO ORADO By: yi4A.,4 Deput lerk to th oard � Barbara Kirkmeyer, hair OCT 072015 APPROVED AS TO S B Elsa,� R ...�.., E - ted Offi ial or Depa +%-nt ONTRACTOR: Brown, Rachel 2809 W E. Street Greeley, CO 80631 By: �►- $- s-LSD Contractor's(or designee's) Signature and Date By: Contractor's(or designee's) Signature and Date 020/5'_ c3a 7� 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 Brown, Rachel, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1640956. 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 .e. .. _ . j. .,.......... • 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 he 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. ?. 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 1 I 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. 11. 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 I-iuman 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. Pl. How often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. I low much time is the provider required to intervene at home and/or at school with the child in Select One _ conjunction with a regular or special education plan? 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. I low much time is the provider required to assist the child because of impairments beyond age Select One appropriate needs with feeding,bathing,grooming, physical, andior occupational therapy? Al. How often is CPA/County case management required?(Does not include therapy) Select One **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. T1. How often are thera• services needed to address child's individual needs •er 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 El Stealing _ Select One ❑ Self-injurious Behavior Select One I -E Substance Abuse Select One Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One 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 Select One complete the Medically fragile NBC) ❑ Emancipation ! Select One ❑ Eating Problems Select One ❑ Boundary Issues Select One ❑ Requires Night Care Select One ❑ Education i Select One ❑ Involvement with Child's Family Select One Exhibit B to the Additional Provisions 13 Revised 6/2014 P.♦ Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) r6s .nk r x 3m -....,.4- 0s' - + .,,,,, -. -3,-,,,,,„Li.:.:,:,,.-.;..,4„,,,�.r t ,- x 'T'F"r ,� .,- y, y '-G 'IY#F S- ka .OF., f, tl t 8 11.4:i .t% , N } yr d vY� is v ' k.} Y'•-t'it,;,*:;';' > �9 6' 5 F r� y�u) a'r'k-. c� .H awr'� �! ] � .� �s v. s i vic y. � 1,--. )-f= t y � H — �; c.+t0.t$ �§.As, y$, .n ``` ..�` f 5 �3 I `s q , +� +*4 ., i .-1.',.,,4'!-§r1 �C3s? L'"1 c.,r, t 7"r �Z, ., �^ .' 4:."rs5 t n° - 1t,° ,,,-,1::k:1'- . �.-.n 'T. ', { ryt�e. c x� YA a 4 �$ k rya h,>.t0 ii-4:11-1:',A,:,. � � �; 1..:. ,---,-..` y ', .a ,c. 4�- , .- . v '� .A E'"A /,:;; a k$ 59 },d r '; b +g iz ef7 y •`w' 3ar „'`� #, w+�r g ks '��k e a 3& ;u tcir r� $12.35 -4 a County Basic ' Age 0-10...$17.01 r $0.00 $.66 No crisis intervention,Minimal ;. v Maintenance Age 1 l-14...$18 81 Not needed or cover Rate - Age 15-21.._$2009 �r '�°-' CPA involvement,one face-to under Medicaid. k face visit with child per month. '. �' �x $15.77 $5.14 442, i t Minimal crisis intervention as "1'. Regularly Scheduled 1 $20.56 $.66 needed,one face-to-face visit4i,,,.:1' R'" $3.45 ,; ,,, P= therapy up to 4 ,; per month with child.2-3 se hours/month. contacts per month t '/: -' $23.99 $.66 ' $17.48 x Ott ' �- 41' t4 Al $19.20 $10.28 Week1 scheduled �k r occasional crisis intervention as ,. Y 2 $27.42 t4• $.66 needed,two face-to-face visits therapy 5-8 hours a $4.97 b- with child,2-3 contacts per , ' month with 4 hours of Fig;; month i group therapy. 2 V. $30.85 $.66 $20.9144 zr+ $15.42 ti $22.62 T" • ; Regularly scheduled 3 Win- Ongoing crisis intervention as �. weekly,multiple is -' "' needed,weekly face-to-face p 3 $34.27 $.66 sessions.can include ? $6.50 visits with child,and intensive '�`• more than I person. -: coordination of multiple i.e. family therapy,for J. services. 9-12 hours/monthly.• M 31/2 $37.69 $.66 '.. $24.34 i',%.4 Y $26.05 '_-'." Ongoing crisis intervention as t needed,which includes high i Congregate $41 13 $¢;, $.66 level of case management and x.p Negotiated Negotiated Care ',, ,µe,; g CPA involvement with child and ; Drop Down . ;„ provider and 2-3 face-to face -`-: . , contacts per week minimum k Ri. 'Mtl flna Y{, tse K'"Of R Y i d;.. �,A '-'''' - '' '�• 7 6<' Y Assessment! 1 Emergency $27.42 ' $.66 •'t $19.20 * , Level Rate �� :,= i I . CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 7day ofatiti-A-6t), 20/P ,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 Buck,Jamie and Lynne, whose address is 1525 San Juan Circle, Evans,CO 80620, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015,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. U. 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. 02O/6--L%2o2 (k) 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. l6. 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: I. 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services,the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. 1. 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. .1. 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. §8-17.5-102(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-I 7.5-102(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- (03(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: I. Are not presently debarred, suspended,proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not,within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain, or performing a public (federal, state,or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local)with commission of any of the offenses enumerated in paragraph (B)above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions(federal, state, and local)terminated for cause or default. N. In addition to terminating this Agreement, in accordance with the provisions of Section 1., 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: A ITEST: C/,.‘trditeA/ aC.0;,,k BOARD OF COUNTY COMMISSIONERS Weld t unty Clerk to the :oard WELD COUNTY,COL DO By: Deputy lerk to th �°� Barbara Kirkmeyer, d'1air rte ' PCT 072015 APPROVED AS TO :S d ted Off' tal or D CONTRACTOR: Buck,Jamie and Lynne 1525 San Juan Circle Evans, CO 80620 B (7 .. 86' Z -'/ ctor's(or designee's) Signature and Date By: ,s•�---' , —L�I�/ ntractor's(or designee's)Signature and Date aa (1) CWS-7A Individual Provider Contract 9 Revised 6/2015 f y ,f 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 Buck,Jamie and Lynne, hereinafter referred to as, "Contractor." GENERAL PROVISIONS I. 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 1D# 1643264. 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`"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 (FI DOS). 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 a,..-.n.,.. _ w ... ,� w 'iWilf ____* 8 7wM1' 7 1y M..• •� .., ..,,`Yid'Ii[ _ ,r. 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 I. 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: Select One Therapy;Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera. services needed to address child's individual needs •er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ Runaway Select One ❑ Sexual Offenses Select One ❑ Inappropriate Sexual Behavior Select One ❑ Disruptive Behavior Select One 1 ❑ Delinquent Behavior Select One ❑ Depressive-like Behavior Select One ❑ Medical Needs-(If condition is rated"severe",please Select One complete the Medically fragile NBC) ❑ 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 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) 4 { a si°,cs 'x' K', '4C. z �E % s` '�Vx" ..y'?t 5Ck t` x 4 . ',-'&-%''-,•..--45••';,,,-„',,i C r W'i ',ry ,{" 6rt y`v ,,a i' w°,-i:i�S� 2 r3} ' : - rakrg.# ::r `''G• " h4 a ,� 'w xisa z l r k l','-`1.11A,',:.',�;g x at r ,j '-, 3� '�.,,.=. 1:,:,''' k',a. . ;n,.a. f .aa..,t- ':r, Xyd ' iA.. °�° : . '� ��c� s. 4*� r�z. i. ,.�. 4.-•, 'k ua�°,;. p $12.35 Rs County Basic Age Q-10 ,517 01 $0.00 >' vz. 5.66 ;y'==- No crisis intervention,Minimal , Maintenance Age 11-14...518.8 I Not needed or cover E,, , C{A involvement,one face-to- r , Rate Age 15-21...520.09 under Medicaid, face visit with child per month. tt= Ai $15.77 $5.14 ?r- ,:k- ,$t« Minimal crisis intervention as ' Regularly Scheduled 1 ,E $20.56 k° 5.66 needed,one face-to-face visit $3.45 t therapy up to 4 w per month with child,2-3 hours/month. •' . contacts per month $23.99 $.66 517.48 ._ -- �.. ffi $19.20 '-'•: $10.28 rk Occasional crisis intervention as Weekly scheduled 2 '; $27.42 it.'. $.66 ^c A therapy 5-8 hours a ,a7,-,,11, $4.97 needed,two face-to-face visits f_ '^ r ` '` month with 4 hours of with child,2-3 contacts per month ,'; group therapy. 2'/z ''55 $30.85 $.66 $20.91 T R.:_ t' $15.42 "': $22.62 , `- Regularly scheduled .t ' L4i; Ongoing crisis intervention as '- weekly,multiple •1-' $66 needed,weekly face-to-face 3 `;,,i4 $34.27 . sessions,can include $6.50 f; visits with child,and intensive �, •6 r more than I person, -., coordination of multiple z 's ie.family therapy,for services. Via€ 9-12 hours monthly. 3 1/2 $37.69 5.66 $24.34 I..."';' ---------- 34 P3 $26.05 Otte 7'e+ '''''r4,,,:;,.1::.:'14" SJ; - Y i Yf '.:+.4 --14. Ongoing crisis intervention as 4 -1 °E needed,which includes high Congregate r g $41.13 s $.66 level of case management and Negotiated Negotiated Care a g fr =: Drop Down ° xx CPA involvement with child and ,�� k'° provider and 2-3 face-to face y ;: :+ firs contacts per week minimum. s`.' I 61A 44,,V.,-' � }. .*� rtyea' �v '� .,mvm +,w' taba"'�.'e+r.96 "�' w,iG' , 4i..ds c..ti>,, .'1),,,,,&'-••. .,,.,ses.�s_ �.1..2� Assessment 1 44 Emergency h44, 527,42 5.66 $19.20 Level Rate s2 CWS-7A Individual Provider Contract 14 Revised 6/2015 /l7It/9' INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this /' day ofat4--(.A-I-4-1, 20/5, 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 Bunton, Sammy and Stephen,whose address is 3405 Burlington Ave, Evans, CO 80621, 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: I. TERM: A. The term of this Agreement shall be from July 1, 2015, 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: I. 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. ilsileALAJ ag,0 /6-3.2.2,2 N CWS-7A Individual Provider Contract 1 Revised 6/2015 /6 - I' 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 ?s tt.I ... ,sd".Y.. 'h''M Nn:YJY r !""M" a:V ti:"•WY,• -... ...... .,., ....J,....,,,,.. ,�,. �... - ..� ....:..,..,a .v,... ,, e..v ..,.. ...m ... 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 I. 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. §8-17.5-102(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: ray ;vi BOARD OF COUNTY COMMISSIONERS y Weld erk to the B and WELD COUNTY, COLO DO By: A-ay_I-A— Deputy lerk to the B . ar ara Kirkmeyer, C air OCT 0 7 2015 APPROVED AS TO SU ,� ; La Electe~' fficial • Dep rr�CONTRACTOR: Bunton, Sammy and Stephen 3405 Burlington Ave Evans, CO 80621 <:. -') 4: '47- 7/7-S-1(r Contractor's o designee's) Signature and Dat By: } Z< /' . ...5-7/ Co' ractor's (or designee's) Si natu e and Date CWS-7A Individual Provider Contract 9 Revised 6«015 02,0 76—3 (g) 1GG, 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 Bunton, Sammy and Stephen, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1642868. 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 ._. . 1.... .0.. _... A _ 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 I I 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 I. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera. services needed to address child's individual needs .er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 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) LEVEL OF CHILD ADMINISTRATIVE ADMINISTRATIVE MEDICAL, SERVICE 1 AINTEN lNCE RESPI"1'F: MAINTENANCE SERVICES NEEDS Level r� Daily Rate 4:'.� Daily Rate • $12.35 County Basic Age 0-10...$17.01 $0.00 $.66 ' No crisis intervention,Minimal )laintenance Age 11-14...$18.81 Not needed or cover - CPA involvement,one face-to- Rate Age 15-21...$20.09 under Medicaid. „. face visit with child per month. IF $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled I $20.56 $.66 needed,one face-to-face visit $3.45 therapy up to 4 per month with child,2-3 hours/month. contacts per month I ' $23.99 $.66 $17.48 $19.20 $10.28 NI Occasional crisis intervention as Weekly scheduled 2 $27.42 $.66 needed,two face-to-face visits therapy 5-8 hours a $4.97 with child,2-3 contacts per month with 4 hours of month group therapy. 2'/2 $30.85 $.66 $20.91 $22.62 $15.42 Regularly scheduled , Ongoing crisis intervention as weekly,multipschedue led 3 $34-27 $.66 needed,weekly face-to-face sessions,can include 56.50 visits with child,and intensive more than I person, coordination of multiple i,e.family therapy,for services. 9-12 hours/monthly. 3 1/2 I 5';''''69 $.66 $24.34 $26.05 4 Ongoing crisis intervention as Congregate needed,which includes high 511 I? $.66 level of case management and Negotiated Negotiated ws Care CPA involvement with child and Drop Down provider and 2-3 face-to face contacts per week minimum. ill NiiiiiMiiiiiiiik Ai 1 Assessment/ .. ill Emergency ti',.I' 5.66 $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this S ') day of 64 , 20 �J , 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 Crews, Paul and Kim,whose address is 407 7th Street, Mead, CO 80542, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015,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: I. 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. / Cif '4�Y 020/5-3.7,1„.2 (/d CWS-7A Individual Provider Contract 1 Revised 6/2015 Jo— 7— /�- 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. 13. 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services,the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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. 0. 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: dged44) W 'JCL; BOARD OF COUNTY COMMISSIONERS Weld ty Clerk to th Board WELD COUNTY, CO ORADO . By: L L Deputy lerk to th oar. , 67batit, ara Kirkmeye , Chair ♦ OCT 0 7 2015 APPROVED AS TO SU: �!�► 1^ .,•,. .��S • a At AL... WA At.:.-OA, as E e - Official IT—I ep. U�. ' - `4c,, '� s* N. 411.4a„ �„y► CONTRACTOR: Crews, Paul and Kimberly 407 7th Street Mead, CO 80542 By: i,' Contractor's (or signee's) Signature and Da By: (301k Con ctor's (or designee's) Signature and ate 024/5-309-a 06) CWS-7A Individual Provider Contract 9 Revised 6/2015 \C 1 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 Crews, Paul and Kimberly, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1648992. 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 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. 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. 11. 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: Select One Therapy;Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc., as outlined 1 in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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? 1 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) Select One **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. T1. How often are thera. services needed to address child's individual needs .erNBC assessment? Select One I 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 ❑ Substance Abuse Select One ❑ ' Presence of Psychiatric Symptoms/Conditions Select One O Enuresis/Encopresis Select One ❑ Runaway Select One ❑ Sexual Offenses Select One O Inappropriate Sexual Behavior Select One Disruptive Behavior . Select One 1 ❑ Delinquent Behavior Select One ❑ Depressive-like Behavior Select One El complete Needs-(If condition is rated"severe",please Select One complete the Medically fragile NBC) ❑ Emancipation Select One ❑ Eating Problems Select One ®—. Boundary Issues Select One l 1 ❑ Requires Night Care Select One pu. Education Select One Ilia_ ❑ Involvement with Child's Family Select One Exhibit B to the Additional Provisions 13 Revised 6/2014 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT Lk.sV- , 20 15 ,by and THIS AGREEMENT is made this \ day of County, behalf of the Weld County between the Board of County Commissioners of Weld Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County,"and Eckhardt, Shawna and Mitchell,whose address is 505 54th Ave.,Greeley,CO 80634,hereinafter referred to as,"Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: 1 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 0O Home with which such certification standards that shall be maintained during the term hereof J and WHEREAS, County may, but shall not Q orb rebe quest chdsery purchase s tobe provided to any child at the County or any duly authorized agent may..= any time within the limits of the certificate/license and without prior notice. iNOW,THEREFORE, in consideration of the mutual promises and covenants made il herein, County and Contractor agree as follows: A I. TERM: % A. The term of this Agreement shall be from July 1,2015,to and until June 30,2016, or until the facility certificate/license is revoked or suspended. r, 5 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 children) may be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further a; 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 y 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 a type of facility and individual child rates negotiated between the county and the provider. f °f 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed., ae : ikg(41(-' 0.Z,O 0-2 02.0aA (fl ) Revised 6/2015 CWS 7A Individual Provider Contract /6` 7-/5 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 e as changed �n the Famin mutual gy Services Plan. reement of the provider and the County Department, 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. 2 Revised 6/2015 CWS-7A Individual Provider Contract 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 c compliance with the Health Insurance Portability and Accountability A (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 . 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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 t40.0010.~ r 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. U. 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 he 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. a' 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 ?.... "LT?.as,.Y xui'3'15 ,.ek₹d `-eNA✓M'rG'. P. , VC!<h,4 -+mom'. V WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: p.II BOARD OF COUNTY COMMISSIONERS Weld u ty erk to the oard WE D COUNTY, CO ORADO By: - lerk to the and arbara Kirkmeyer, Chair4t.� eputyOCT 0 ? 2015 APPROVED AS Tl SU T��t�'�""�'+1 E • t d O 1orDepa,/yen361 I TRACTOR: Eckhardt, Shawna and Mitchell ;t 505 54th Ave. Greeley, CO 80634 Y. �► �t I_..��,�!'i1►i'�► 1 5 o ractor s(or •esig ee's) Signature an Date / Contrac is (or designee's) Signature and Date CWS-7A Individual Provider Contract 9 Revised 6/2015 ii 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 Eckhardt, Shawna and Mitchell, hereinafter referred to as, `'Contractor." GENERAL PROVISIONS I. 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# 1644218. 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 4h 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. 11. 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. Pl. How often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. TI. How often are the services needed to address ' 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 Substance Abuse Select One Presence of Psychiatric Symptoms/Conditions Select One Enuresis/Encopresis Select One Runaway Select One Sexual Offenses Select One Inappropriate Sexual Behavior Select One Disruptive Behavior Select One l Delinquent Behavior Select One Depressive-like Behavior Select One ❑ Medical Needs-(If condition is rated"severe",please Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 6/2014 J Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) 3 I.E.NEl.OF CIIILI) AtmiNtsTRylIV'E ADNIINISTRATI 'x ' r'' RES1+1'1'E SERA l( MAINTENANCE MAINTENANCE SERVICES NEEDS __..________ Level 1 Daik Rate R Pate Daily Rate I Daily. Rate fv. $12.35 County Basic Age 0-10...$17.01 \66 No crisis intervention,Minimal $0.00 Nlaintenance : Age 11-14...518.81 Not needed or cover Rate Age 15-21...520.09 * •, CPA involvement,one face-to- under Medicaid. face visit with child per month. $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled 1 520.56 S rir, needed,one face-to-face visit S3 t5 therapy up to 4 per month with child,2-3 hours/month. contacts per month I '/: $23.99 5.66 1 $17.48 ------- $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 2 527 42 5.()6 needed,two face-to-face visits therapy 5-8 hours a s 51 with child,2-3 contacts per month with 4 hours of month group therapy 2 '/ S "x yr,n $20.91 $22.62 $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple nee 3 ';i -- S 66ded,weekly face-to-face sessions,can include ti,.>u visits with child,and intensive more than I person, coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. v. 3 1/2 537.69 y i,6 $24.34 ---------- $26.05 Ongoing crisis intervention as 4 Congregate needed,which includes high S11 13 S.66 level of case management and Negotiated Negotiated Care Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. IIIIEIIIMIIIIMIIIIIIIIIIIIIIIIIIFC Assessment/ a3 Emergency 52- 12 ti or ' $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this I s7- day of Ak-)G-_S i , 20 r,5 , 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 Fitzpatrick, Thomas and Cheryl, whose address is 324 Saturn Dr., Fort Collins, CO 80525, 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: I. TERM: A. The term of this Agreement shall be from July 1, 2015, 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. / 4IUU) ,zo 32(2-) CWS-7A Individual Provider Contract Revised 6/2015 /o - 1- /b 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. [II. 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. §8-17.5-102(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. t, COUNTY: ATTEST: �j„ ) G •�C�to;� BOARD OF COUNTY COMMISSIONERS Weld sun Clerk to the Beard WELD COUNTY, COL RADO By: Deputy erk to the B� �w,�y/�� Barbara Kirkmeyer, G air 0 7 2015 APPROVED AS —O S E tad Offici. or Dom a �" w+r►� CONTRACTOR: Fitzpatrick, Thomas and Cheryl 324 Saturn Dr. Fort Collins, CO 80525 By: -2-z.1 Contractor's (or de ignee's) Signature and.,_ate By. Contractor's (or designee's) Signature and Date c4 f7 as (t2 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 Fitzpatrick, Thomas and Cheryl, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1620996. 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`" 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 shalt 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 I I 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. 11. 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 ,rte '.V-K`"'.�' ►l `r 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. Pl. How often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera• services needed to address child's individual needs •er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 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) LEVEL OF, CHILD ADMIMSTR4TIVE A�D1Y11N15TRATIVE MEDICAL ;RESPITE � n 3 � ' SERVICE '4., AINTEN NCE *(104 E1 A E SERVICES DS R S' .✓ is o a n s� 1 � >.r'' r_ v ?.. 5 NEE lagi fi Z a _Level 7 Datty.l,2ate, 'Dat1yRate DailyRate Daily'Rate Da11yRate a County Basic Age 0-10...$17.01 !4,1 $12.3 $0.00 Maintenance Age 11-14...$18.81 $•66 No crisis intervention,Minimal Not needed or cover g CPA involvement,one face-to- under Medicaid, Rate Age 15-21...$20.09 face visit with child per month. $15.77 It. $5.14 Minimal crisis intervention as Regularly Scheduled 1 $20.56 $.66 needed,one face-to-face visit therapy up to $3.45 4 per month with child,2-3 hours/month. contacts per month re 1 '/2 $23.99 :To! $.66 $17.48 � t; $19.20 ;ffg $10.28 itt Occasional crisis intervention as Tit Weekly scheduled 2 $27.42 d, $.66 ` needed,two face-to-face visits therapy 5-8 hours a $4.97 with child,2-3 contacts per month with 4 hours of month group therapy. 2 '7 $30.85 ,;;;; $.66 $20.91 WI' Ai $22.62 $15.42 Regularly scheduled ' Ongoing crisis intervention as weekly,multiple 3 $34.27 $.66 needed,weekly face-to-face sessions,can include $6.50 visits with child,and intensive °' more than I person, id is", coordination of multiple Zif. id'i ;t1 .e. family therapy,for 11 services. 9-12 hours/monthly. 31/2 $37.69 $.66 $24.34 $26.05 a r Ongoing crisis intervention as Congregate �. needed,which includes high e $41.13 $.66 level of case management and i; Negotiated .;;;I Negotiated Care dd: Drop Down iig CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. Assessment/ Emergency $27.42 $.66 $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 141/4Xet 44.d. INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this t-t#' day of AJr.),y"ii� ,20 j5 , by and between the Board of County Commissioners of Weld County;Jon 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 Frederick,April Lynn and Steve Lloyd-Allen,whose address is 14423 WCR 76,Eaton,CO 80615,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 Contra agree as follows: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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. cc: /1c,0-- pZi),5 (, CWS-7A Individual Provider Contract 1i Revised 6/2015 /p-- '7 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services,the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-1 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. 0. 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. dirAtA) COUNTY:ATTEST: G. . 0%t1 BOARD OF COUNTY COMMISSIONERS Weld cki Clerk to the B and WELD COUNTY, CO ORADO By: Deputy Jerk to the Bo arbara Kirkineyer Chair OCT 0 7 2015 APPROVED AS TO S BST j,,� \ La�� Ele ed Offic'.l or De.f �A p NTRACTOR: Frederick, April Lynn and Steve Lloyd-Allen 14423 WCR 76 Eaton, CO 80615 By: U Contt, `rittaliAltr r tor's (or designee's) Signature and Date By: /,sue_^-y��+,1t Contractor's(or designee's) Signature and Date 2Dfc-30102a (ice 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 Frederick,April Lynn and Steve Lloyd-Allen,hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1667329. 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 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. CWS-7A Individual Provider Contract 10 Revised 6/2015 tea..,r u...,iyr,.. X A f.A 4 . 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. 11. 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 . I 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. Pl. How often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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 atte 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) Select One **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. T1.How often are thera• services needed to address child's individual needs .erNBC 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One ❑ complete the Medically fragile NBC) El 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 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) LEVELOE> CHILD ' 3INSISVOM VA rA,r h r 1wr ADIyII1 ISTRAT VEr rtit At.4,010.10w-Omt-MAWE.,5$0 411 ADMINISTRATIVE i xx y: ,, fh:,,,esKT,, :_.3 ."'ems, Aar .,- sSPLTE44.14&..},.:2-""K -,...,,,,.1,-, 9„.70,.‘--v-A'1.- A ✓'� r�'F` ri 'W,It- A' E2�1 .IY4: SERVICE MAINTENANCE� ARE rITE r N CE rO .,. S,,ERVICES� „,'wNEED �y Ay,��It r , i r��.x4 4v .X 0 kpeow"'3°ti'tea `*t is-.04b, t o 'z' *-44,;w'4 , c hMaRsilta 53_t.::. . '� `^,.:. iii;w .r"e,�..+'.�''Y, !:114_..s.�r f:::.." .a='2,-I-44i z.sfry l.'rt EV li'`*"q u- '�. ^." .r' , a.:74-2.201-411g; fr T ``sf>y 5y xx-"'�..,, f„ 'w,.r x"", a -. '.%„� -�a 'xc'�-ftt. x iS 'at s i iSSO r'�.��. 'x.V ti Level 3 DatlyRate Daily Rate DatlyRate DailyRat~e , Dkely teAr !, .,,. 71 .-.;�I } ?.,?mJ�`�'`� ₹ • sl y. tss"' •" 9. a ."}+a &c . ,r' T ( C' 11 .C l,-:.. ..v..r .,. '� .k Ti"'4 - �f '�i"� 's 'A: 44:i �4N. County Basic Age 0-10...$17.01 k- $12.35 $0.00 s $.66 �< No crisis intervention,Minimal , , Maintenance Age 11-14...$18.81 Not needed or cover ----- g fig CPA involvement,one face tot Rate Aiim ge 15-21...$20.09 � 'og gm face visit with child per montha under Medicaid. 4 . L- x:-• $15.77 $5.14 F- Minimal crisis intervention as " 1 $20.56 $.G6 : -: Regularly Scheduled .j-3,..,i% I' - y- needed,one face-to-face visit therapy up to 4 per month with child,2-3 _ ` 024 hours/month. 3' contacts per month 1 %2 $23.99 $.66 $17.48 k ---------- p y , $19.20 . $10.28 Am Occasional crisis intervention as = Weekly scheduled 2 $27.42 F $.66 needed,two face-to-face visits therapy 5-8 hours a �_ $4.97 V51? s month with 4 hours of - � with child,2-3 contacts per ` �� 13 y month ' group therapy. r 2%2 $30.85 r $.66 1M $20.91 $22.62 = $15.42 a1- -k = Regularly scheduled t �' Ongoing crisis intervention as weekly,multiple needed,weekly face-to-face w 3 $34.27 $.66 sessions,can include : $6.50 visits with child,and intensive more than 1 person, 4g,, coordination of multiple . i.e.family therapy,for services. -.4'. ffa 9-12 hours/monthly. i 31/2 $37.69 $.66 $24.34 -' --- ;5i:: u . $26.05 ,F.= r49, 4 - iit . Ongoing crisis intervention as Congregate . needed,which includes high $41.13 $.66 level of case management and • Negotiated b ; Negotiated Care Drop Down CPA involvement with child and !!! r ot provider and 2-3 face-to face contacts per week minimum. Assessment/ _ Emergency $27.42 $.66 $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT I FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT i THIS AGREEMENT is made this �� day of , 20/, ,by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,hereinafter referred to as, "County," and Garcia, Fernando and Aracely,whose address is 3919 28th Ave.,Evans, CO 80620, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: I 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 an I 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: I. TERM: , A. The term of this Agreement shall be from July 1,2015,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. C e2 /-/S ikeit- c,-90/. '-‘3,92.tva02-0 ) CWS-7A Individual Provider Contract 1 / Revised 6/2015 /CI - 7i � ,,,.,>,,., , .. .... .rr.,,. ,u.�,.�, ,"� , :•... ;tr,,., mss- <...�.. � .,. ,;�. .. . ., _ ... ,.,_ ... 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. 1 ti CW5-7A Individual Provider Contract 2 Revised 6/2015 -q tr;. k ._ "'.n ter^^.a ik�...,.. ` ' 'r',E� r:T ,s, ^.: - ,r' ..:a - ��cs . r a. .,,r1=. r� .,�� ,zr. -,Mr,: a _ , r �re.y.S �, � .. r. , P .t� nom": 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 T" °41C 7"*-i'. .x. ="+:at X E+`."''''' a §"u '"C R 3 r °f '§ ': '� s,f *a" .. ", �11 .�z. t., _ > s t 't3.� �.� �.;F:��"+.�.'T:b.�* .r. ��'� `. .;�'�.,. ..� '�y��'s�v;u�,,,��'� �Nv�,.*.. ,�;T,, �9�,�'�`";,�� ,.. rt. ;;,:.,,,T'�`-r,= 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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 z 4'4°"v x.v"ir*f 5 frN 'wi ^nx trk x^?x. '�r, `f ,n<a,v3. f g x. n;et. ...Y,.�r ?k3r�,-'.-.""r' yr " ^`.' s�,� �,`,.-,.AF,., ^-V r `k":' IA 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. fi 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 w. o_,g,Y,,.J� fig',o-,"tL . f -2r. �s r 4',v 0 t � ,,�� x .+u xY "''.�"x ", �� a r4sa,`fih-. v � . tom " ,' �� & �.,� ,�,,�� ts�r.t 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: d..drit..) wxido,ok BOARD OF COUNTY COMMISSIONERS Weld t Clerk to the Bo d WELD COUNTY, CO RADO By • Deputy lerk to the Bo SW( arara Kirkmeyer, hair OCT 0 7 2015 AP ROVED AS TO SUB S La`� A _.�1\ � El-c • Of ici or Depart �'se • � '-,;�+ �+�� j RACTOR: Garcia, Fernando and Aracely 3919 28th Ave. Evans, CO 80620 By: eiG4 Y."' Contractor's (or designee's) Signature and Da By: Co a is (or designee's) Signature and Date ( ( /5-3o2 CWS-7A Individual Provider Contract 9 Revised 6/2015 \ 1 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 re$rred to as,"County," and Garcia,Fernando and Aracely,hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1561879. 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. r j B. Be submitted by the 4"'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 v r ,�' � '„ ,.,, 7 .t,,,:... .... ,. 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. S. 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 o r f Ts IARY,.c..xt 7S •a .yr..mng ,16'm7t . 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. 1 � 10 Maintain/update medication logs on a daily basis, if child is taking medications. 11. 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. II 1� 3 1 # M I CWS-7A Individual Provider Contract 12 Revised 6/2015 .�.x,.',.. ,�.,� ,. ,, ea .," ,;,r .ter ,.� ,' • ,-. ,..., ,K„Fx, ,.F „��,.n,��:_„ c r-,r -.., „��.�`r.t ,�... �,�, �r�x ,TV'' 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: Select One Therapy;Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc.,as outlined Qnce a ,iee IC in the treatment plan? P2.How oftl n is the foster care provider required to participate in child's therapy or counseling Select One sessions? 0 nce c week P3. How mich time is the provider required to intervene at home and/or at school with the child in Dv; One conjunqtion with a regular or special education plan? Jv;ec,- f iii5i D`" P4. How oftn does the child require special and extensive involvement by the provider in scheduling Select Orf and \I u r ilitbl , a r e( monitoring of time and/or activities and/or crisis management? co ri a P5.How mach 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? Norte Al.How o n is CPA/County case management required?(Does not include therapy) Select One **Plea a Note: The Case Management level may be assessed on a combined basis if a sibling gro p or mor than one County foster child is with the same provider. — Ti.How often are thera. services needed to address child's individual needs •er NBC assessment? Select One NBC (NEEDS BASED CARE ASSESSMENT) Behavioral Assessment Assessment Areas: Comment: Rating: a ❑ Aggression/Cruelty to Animals Select One 12 Verbal or Physical Threatening Select One Q Destructive of Property/Fire Setting Select One Stealing Select One Self-injurious Behavior Select One Substance Abuse Select One Pre$ence of Psychiatric Symptoms/Conditions Select One El Enu esis/Encopresis Select One Runaway Select One Sexual Offenses Select One Inai3propriate Sexual Behavior Select One Dis$uptive Behavior Select One Delinquent Behavior _ Select One Depressive-like Behavior Select One Me ical Needs-(If condition is rated"severe",please Select One O complete the Medically fragile NBC) ❑ Emancipation Select One O Eating Problems Select One 0 Boundary Issues ` Select One O Regiuires Night Care Select One O Edcation Select One 0 Inv ilvement with Child's Family Select One f i 1 ' Exhibit B to the Additional Provisions 13 Revised 6/2014 's 1:`,,T..r€'O;. .,ya PwI.... mm's„. sarr-, ,& uz ti f .-" e,,s"�€gtref` fr+'' M�z , S, ` ,r°'?,r.; ^., -,'9 s. .-,7 ,'✓,Tz ,, s1,>'.:�«'^,"-�S A ✓ �,n, a i� ,a ss"Y mss ��—a,nk �` �. .��: . '�`� . 1�" �.t =�" a�T�'ss z,.f . 1 ( , I . Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) LFVl 1.01 (1T11 D AU,Mt IS`I RA 11V'L l AD iILNISTR#7Iv L nl F 1�1t AL SERVICE 1IAI'TENA C.') RESPITEMt1\'1LiNAVCF. SERVICES MELDS Level Dait,. Raft; Daily Rate Daily Rule Daily Rate Daily Kate $12.35 County Basic Age 0-10...$17.01 $0.00 ,,r), No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover Rate Age 15-21...$20.09 CPA involvement,one face-to- under Medicaid. face visit with child per month. $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled 1 $20.56 5 6ti needed,one face-to-face visit $3-45 therapy up to 4 per month with child,2-3 hours/month. contacts per month 1 'V2 523 99 ' ',r $17.48 -------- 5 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 2 `' 1' ti' ' needed,two face-to-face visits therapy 5-8 hours a $4.97 with child,2-3 contacts per month with 4 hours of month group therapy. !, 2 ! $_ w r:;r, $20.91 M I $22.62 $15.42 Regularly scheduled I Ongoing crisis intervention as weekly,multiple 3 S-H ' ,,a„ needed,weekly face-to-face sessions,can include $6.50 visits with child,and intensive more than 1 person, coordination of multiple i e.Family therapy,for :.. services. 9-12 hours/monthly. 3 1/2 S'31 r,9 $"u $24.34 _ ---- $26.05 Ongoing crisis intervention as 4 needed,which includes high Congregate $41.13 0,, level of case management and Negotiated Negotiated Care CPA involvement with child and Drop Down provider and 2-3 face-to face contacts per week minimum. — — -- Assessment,' Emergency $27.42 $.66 $19 20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 ii /7) �a- INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this day of $(2-C--/-6,11-), 20/"1, 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 Grizzle, Phillip and Nicole,whose address is 4380 W 23rd Street Dr.,Greeley,CO 80634. 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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 children)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. e; 6 G� O2O°—`5°291a1 Ci) CWS-7A individual Provider Contract Revised 6/2015 /0 -7 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. I.I 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: I. 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. C W S-7A Individual Provider Contract 4 Revised 6/2015 I 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. Ill. 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. L 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-l7.5-102(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. 0. 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 he 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 he 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: � i _� p'11 BOARD OF COUNTY COMMISSIONERS Weld ty er to�( e Board WE COUNTY, COLDO By: L rdtrkrney , P' r' OCT 0 7 2015 APPROVED AS TO S BS 3s La E -c ed Offi'ial or De rt ✓�NTRACTOR Grizzle, Phillip and Nicole 4380 W 23rd Street Dr. Greeley, CO 80634 • By: C AO 8/MPS Contractor's natue(or esigne ' 'i g g and Date By: ,. • SW IS- Contract or designee's) Signature and Date 0.2.0/5—c, (/5) 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 Grizzle, Phillip and Nicole, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1629745. 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 bcd 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 4rh 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. 11. 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: Select One Therapy; Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera. services needed to address child's individual needs .er 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 E Stealing Select One Self-injurious Behavior Select One 01 Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 D Medical Needs-(If condition is rated"severe",please Select One complete the Medically fragile NBC) ❑ Emancipation Select One ❑ Eating Problems _ Select One ❑ Boundary Issues Select One I ❑ Requires Night Care Select One ❑ Education Select One E 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) - r4Kz-4 g. '.- 'T-41) `''' Sat_ �r""`.,. zaW . LI;Y'k l OF r 1) ADMINISTRATIVE '5 rs,' iS ens 'r R ' S1 R%'It E 'tA1NTEt A'CE h1AIN'TEi4ANCl "` �� 'z ir,,,,,,,„::::".::...1.,-:,:::,:;::-:::::,' ,f Level lla :� ' R a `'Jtate ` L1tul Rate arty ' $12.35 County Basic '' Age 0-10...$17.01 $0.00 5.66 No crisis intervention,Minimal Maintenance Age 11-14...$18.81 `. sNot needed or cover '' Rate ,,.,: Age 15-21...$20.09 CPA involvement,one face-to- t-','',' under Medicaid. K.° v, fax visit with child per month. S15,77 ,li$ $5.14 Minimal crisis intervention as x.{ I $20 56 $.66 Regularly Scheduled needed,one face-to-face visit therapy up to 4 5'45 per month with child,2-3 : hours/month. ''',4t rairk contacts per month N. -t.I '/, $23.99 $.66 $17.48 r tom. $19.20 $10.28 Occasional crisis intervention as14'7 Weekly scheduled 2 527.12 ;ryt $.66 therapy 5-8 hours a 4171.: $4.97 needed,two face-to-face visits with child,2-3 contacts per , month with 4 hours of month , group therapy. t.i.' 2 '/2 t" $30.85 5.66 $20.91 • - ---- --------- 4410ilf. $22.62 P $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 $34.27 $.66 __ needed,weekly face-to-face $6.50 sessions,can include 5., pig- visits with child,and intensive more than 1 person, "t`` w 4 , s; coordination of multiple t, ," i.e.family therapy,for services. 9-12 hours/monthly. 4 r 3 1/Z n $37.69 • $.66 $24.34 --•--• 7; ,44 .' ,,,,L �F $26.05 , 4 Ongoing crisis intervention as ek, "fix needed.which includes high Congregate €` ('arc $41.13 4 $.66 level of case management and Ne ��tinteJ T- Negotiated Drop Dow n CPA involvement with child and provider and 2-3 face-to face t contacts per week minimum. `' - , - it4aZ, ,77"7'''r ' ''' .7''''I''''''' ' I.-•---* 'i.-_,pita ,':,,,AT,,,,-e-- ---,-= d• Assessment/ H Emergency $27 42 $.6t, $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 ..mow - INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AG MENT THIS AGREEMENT is made this/lid day of , 20/ , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Risler,Jason and Hadley-Risler, Tamara,whose address is 3717 Soderburg Dr, Fort Collins, CO 80526, 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 July 1, 2015,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. CWS-7A Individual Provider Contract 1 Revised 6/2015 /D - I-� I� 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: I. 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. §8-17.5-102(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: I. 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: A'I"I'F.S`t ddritet) r. to,&k. BOARD OF COUNTY COMMISSIONERS Weld t Clerk to the B and WELD COUNTY, COLO t.ADO By: Deputy erk to the 130 arbara Kirkmeyer, CI air OCT 0 7 2015 APPROVED AS TO SUBSTANC La E coed Offic al or D- arts = t 1861 �;;per" 4 RACTOR: dley-Risler, Tamara and Risler, Jason 3717 Soderburg Dr Fort Collins, CO 80526 By. o ra r s (or est ee's) gnature and D e By: / G C ntractor's (or designee's Signature id Date x/53 06' C';WS-7A Individual Provider Contract 9 Revised 612015 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 Hadley-Risler,Tamara and Risler,Jason, hereinafter referred to as, "Contractor." GENERAL PROVISIONS I. 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# 1631808. 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 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. 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are theras services needed to address child's individual needs ler 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ Emancipation Select One O Eating Problems Select One ❑ Boundary Issues Select One ❑ Requires Night Care Select One ❑ Education Select One O Involvement with Child's Family Select One Exhibit B to the Additional Provisions 13 Revised 6/2014 rimmimmismr Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) ., RESPITE SF RN ICE NI kIV"FE'VANCE NIA1NTENANCE SLR.%ICES 'SEEDS l..esel -1 Rate Dail Rate •, t .'; *ass n . a ,.» Daily Rate _ .: . County Basic Age 0-10...$17.01 $12.35 $0.00 5.66 No crisis intervention,Minimal \laintenance Age 11-14...$18.81 Not needed or cover Age 15-21...$20.09 CPA involvement,one face-to- Rateunder Medicaid. face visit with child per month. , II $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled `~10.56 $.66 needed,one face-to-face visit ''c" S3 4' therapy up to 4 per month with child,2-3 hours/month. contacts per month I '/2 , ; 99 `6 6 $17.48 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled Z $27.42 S 66 needed,two face-to-face visits therapy 5-8 hours a $4.97 with child,2-3 contacts per month with 4 hours of month group therapy. 2'h $30.85 `;_66 $20.91tii • $22.62 $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 ,,,t ,66 needed,weekly face-to-face sessions,can include 5650 visits with child,and intensive more than I person. , coordination of multiple , i.e.family therapy,tiir services. 9-12 hours/monthly. 3 1/2 $37.69 s 66 $24.34 $26.05 4 Ongoing crisis intervention as *re� needed,which includes high Con k Ia[c $41.13 ".66 leveCPAlinvol of casevement managementhild and Negotiated Negotiated (are Drop Dona n with c and provider and 2-3 face-to face contacts per week minimum. i Assessment/ Emergency $27.42 S 66 $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this day of , 20/O--, by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,hereinafter referred to as,"County,"and Heard,John and Kimberly,whose address is 109 Hunters Cove Dr.,Mead, CO 80542, hereinafter referred to as,"Contractor." This Agreement covers all children placed by County with Contractor. WI`I NESSETH: 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: I. TERM: A. The term of this Agreement shall be from July 1,2015,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: I. 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. pis �,''�' o/ -3W 6-7) CWS-7A Individual Provider Contract 1 Revised 612015 )0 _ 7- ' 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. 1 I. 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 6/20 I5 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services,the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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 he 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. 1-I. 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. §8-17.5-102(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 1., 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: l. 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 he 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. CyC COUNTY: ATTEST: `'t/, ,�` �• 'g1 BOARD OF COUNTY COMMISSIONERS Weld 'o nt,Clerk to the Bo.,d WELD COUNTY,CO O.RADO By: Deputy C S rk to the Bo Barbara Kirkmeyer,.thair T 0 7 2015 APPROVED AS TO SUB �►'} � �`� E c ed Offic':or De•f enifir A, �t','.•`'�►'' �l ` ► +�ONTRACTOR: Heard,John and Kimberly 109 Hunters Cove Dr. Mead, CO 80542 By: 4d /$ Co tor's es gn 's) Signature an ate By: (5- ractor' (or designee's) Signature and Date 040 7,. --,502,01A-0-1) 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 Heard,John and Kimberly, hereinafter referred to as, "Contractor." GENERAL PROVISIONS L 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# 1624256. 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 writinP by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five(25)calendar days of the month following service, it may result in forfeiture of payment. 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 1 I 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. 11. 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 S-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. P I. How often does the child require transportation by the foster care provider for the following: Select One Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera. services needed to address child's individual needs Der 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Li complete Needs-(If condition is rated"severe",please Select One complete the Medically fragile NBC) ❑ 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 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) y a f F��'.D ry�"NY " � o�,�' ,..,�.-v,'„-.4.N-4: r�. X1.1. �.r4,- ,,,I, ahi :. �,,y�,>x��r �4x 4� _ ! , ..Y k `L ' `.1 it 3 l i' 'r 7 �}iY iI {t- $ i 7 A te€ rt'a i dki 7 � d; ₹'l ay f ya ,,1f.A a '`.P a ,4'a i+ m' 'lv '+t m rt a �r J: 9 .c ' H,'5r ` �/,, i`;�rk ,s ,i J fi .r r n s,, ..ro�R S 1' `9'a ,;a ,roan � z I �' :a r t 4'' 1" 4u a M. '. ��:—e444 s e' .," '' 4:-.4,1,,:.v, z� r 9 x is 'r VteI '$' s w � a �+E : 4 ct Nit to , `1.4'7- �,S; v , r ` i.., w': e�t•x;a v';w» "' `rr: . ;, .g. .;41 `r 1 Lie.i_t.tx sa1aL a s 512.35 County Basic Age 0-10...517 01r ._ , i1 5,66 No crisis intervention.Minimal i- $0.00 Maintenance Age 11-14...518.81 `'`` Not needed or cover ,,;t ,. CPA involvement,one face-to- 6 Age 15-21...520 09 -_ ;; under Medicaid. Rate .{a t`> face visit with child per month. Ot _, $15.77 . $5.14II `s" Minimal crisis intervention as -. 1 $20 SG } Regularly Scheduled . $•66 - needed,one face-to-face visit - $3.45 ": therapy up to 4 per month with child.2-3 a hours/month, r ° ,3 ,v contacts per month 1 '/s $23.49 r$.66 :i; $17.48 ----------- k $19.20 $10.28 7' ki , ,[;. Occasional crisis intervention as Viieekly scheduled ". 2 $27.42 $.66 needed,two face-to-face visits therapy 5-8 hours a 7 $4.97 , with child,2-3 contacts per month with 4 hours of Y f month group therapy. ':.14,1 2 V2 $30.85 t 5.66 �- $20of, .91 ._ A x $15.42 $22.62 Regularly scheduled Ongoing crisis intervention as ,M .. ti weekly,multiple .' needed,weekly face-to-face is 3 $34.27 $.66 sessions,can include h $6.50 visits with child,and intensive �. t"� more than I person, coordination of multiple '. i,e.family therapy,for services. t ,, i 9-1_hours/monthly. 3 1/2 off 537.69 .. y 5.66 $24.34 A. $26.05 ; 4 Ongoing crisis intervention as ri'f-,,:.'*'.,; :„i ,.. ». T< needed,which includes high t r Congregate ,p 5.66 y' 4' Ne otiated c Ne Negotiated $41.13 level of case management and g 6 Care t;. Drop Down ,di • CPA involvement with child and } l+ provider and 2-3 face-to face '° i ~. contacts per week minimum. d �.��3-'.��"" �.�`a.fie- .,...fir <4+�' gl �1}:2 „ *��-•.,m�,.w ,` ��a��a � ,�,. r":� .,s„ �, ,' . 14,4 Assessment/ t= + a Emergency r;:- $27.42 $.66 $19.20 ' Level Rate ' t, CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 'day of OA t.ISt- , 20 15, by and between the Board of County Commissioners of Weld County, o'fi 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 Heimer, Sara, whose address is 3000 NV 19th St, Greeley, CO 80634, 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: I. TERM: A. The term of this Agreement shall he from July 1,2015, 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 children) 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. 026 4 -302'ali (10 CWS-7A Individual Provider Contract Revised 6/2015 /0 1 / 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: I. 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 6/20I 5 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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 62015 • 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 R Revised 6'2015 WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. I4Z4&) COUNTY: ATTEST: v• ' BOARD OF COUNTY COMMISSIONERS Weld o n Clerk to the B and WELD COUNTY, COLO DO By. Deputy lerk to the B d Barbara Kirkmeyer, affair OCT 0 7 2015 APPROVED AS TO SU:STA S ada, El- t-d Official or Dep art nt ', , '"� " �l 1861 � '•,nr►�� j TRACTOR: Heimer, Sara 3000 W 19th St Greeley, CO 80634 By: ��-� �� CZ—1- 1 6- -Contractor's (or designee's)Signature and Date By: Contractor's(or designee's) Signature and Date CWS-7A S-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 Heimer, Sara, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1.547292. 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 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. 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: I. 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 F1DOS. 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 hinder. 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. 11. 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. Pl. How often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. Flow often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T_How often are thera. services needed to address child's individual needs .er NBC assessment? Select One NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment j 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 ❑ Enuresis/Encopresis Select One ❑ Runaway Select One O _ Sexual Offenses Select One r�} 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 Select One complete the Medically fragile NBC) ❑ Emancipation Select One ❑ Eating Problems Select One ❑ • Boundary Issues - Select One-- I ❑ Requires Night Care . - Select One ❑ Education Select One ❑ Involvement with Child's Family Select One Exhibit B to the Additional Provisions 13 Revised 6/2014 1 Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) ' ,''',"•',,,,` r ; •°'. " ' fi'a # ''q, '�'$e-7`�ii'nk' T 4;.f. _ TN , - ',i .,;k, ,=#z d'x `:s. 3,,,,,.-1..0.:_:- T rV 'QE k'3{ t�. ii0a �1."°i s -4,,,,,,,,,,,,,,,,,,, , ,,s,. it V,�11 l4 c '�{ 3 �' a 3a f j j5 ri' 5'�. i n s v,' a r -.",at t . + ) �":orifir4tt,.,-a... .--. 4.-,.., ,i,v,vittAt —.,t-; „� !-Xs c a ' •. �: ,4a � r -3 /tee_Sr.4rtait, , .a i sfik� r W.Y ». .3 6 's+ ),. L �' ca "' t JMr Js., ,..$ ',4t; sr a yak , ''��a5n Sax^ �. "` fir,„.,.-ylas.,,q V r„,,,,,-,':.:,* :.t= f,�'. t; a ��,, _: .,. .e �,G ,, ,' �'�„ ,4 `a �evC "�rt Y 040'04 •� � 9 :41 4 i ;-':#`,4c.!-'-''.'''-•.''` T '¢ Vr ,gam TF 3{ -. 'c.'.p aj 7tt "„l!1 C e n..., ; r, f.. w,r a —F, °' .;:,.1«' y, },,w. - s tta.� '�₹.r.;.f.6s;:tm? r`5 ' $12.35 County Basic ,. Age 0-10...S1 7.01 . :. 5.66 No crisis intervention,Minimal $0.00 . Maintenance Age 11-14._$18.81 �F Not needed or cover Rate > Age 15-21...520.09 C[A imolvcment.one face-to- ,'f under Medicaid. ,/; 'Al: :, face visit with child per month. i.t` $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled 1 $20.56 $.66 needed.one face-to-face visit therapy up to 4 per month with child,2 3 hours/month. ' contacts per month r.,,-,,,,,c,f- ',•?,;,.-, +w 1 V. $23.99 • $.66 $17.48 A' $19.20 $10.28 Occasional crisis intervention as , . Weekly scheduled --.„,....--`t,,,,,, 2 $27.42 5.66 needed,two face-to-face visits therapy 5-8 hours a $4.97 with child,2-3 contacts per month with 4 hours of t month t- group therapy. s• • 2 '/i $30.85 5.66 $20.91 ; kPL $22.62 $15.42 ' r• Regularly scheduled - Ongoing crisis intervention as R :f-,:',,,n weekly,multiple V:., 3 ' $34 27 : $66 needed.weekly face-to-face ` sessions,can include $6.50 visits with child,and intensive '' more than I person, 'sir--. coordination of multiple i.e.family therapy. for services. 9-12 hours/monthly. 31/2 $37.69 $.66 4,. $24.34 ,".4,0,..:,,',. $26.05 'F 4 Ongoing crisis intervention as ems: a'; needed,which includes high Congregate f- $41-13 � g -*$.66 level of case management and `, Negotiated Negotiated 4. Care ,,, ,, ate Drop Down CPA involvement with child and ' x'r' ='- provider and 2-3 face-to face :, Vii: t •' contacts per week minimum. Assessment/ K c Emergency •• $27.42 4 5.66 $19.20 : Level Rate - w � CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AG EMENT THIS AGREEMENT is made this / day of , 20 / ..7, 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 Hernandez, Roberto and Margarita, whose address is 912 Elm Ct, Fort Lupton, CO 80621, 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 WI-IEREAS, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015,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: I. 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. - sue c20/53 ) CWS-7A Individual Provider Contract 1 Revised 6/2015 /b — ? - / 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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 teens 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 andior 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. detrAN) COUNTY: ATTEST• v• 'eik BOARD OF COUNTY COMMISSIONERS Weld ou'it Clerk to the Bo rd WELD COUNTY, COL RADO By: Deputy erk to the Bo �w�„ :arbara Kirkmeyer, ' hair idLa�� OCT 072015 APPROVED AS TO SUBS;r s El- t d Officia +r Depart Y. t ONTRACTOR: Hernandez, Roberto and Margarita 912 Elm Ct Fort Lupton, CO 80621 By:7 (or designee's) g— '' O/(5— Contractor's ' Signature) and Date By: � PAA C— on tf/actor's r designee's 'gnature and Date a.2.0/.1--22'2//1) 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 Hernandez, Roberto and Margarita, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1520297. 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 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. 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. 11. 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: Select One Therapy; Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are therat services needed to address child's individual needs .er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 El complete Needs-(If condition is rated"severe",please Select One complete the Medically fragile NBC) ❑ 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 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) ' 44 4� e'i, rx ' "I. ,a'hit 1 P(#�,'_, _� -:.w t '`e`$ JCA #'4-- - �ar n UM I -.S- Li. .� r-Akj 3-1 �Yt h a t ;1 air Vvi oaf: 'p w < .,o, r.,, d r .41 fi r p M x : :.aa i'''.1 1�C��F � V� d .t '� � � � tx�x 7 *�' � Ft� a1„{�+9'Sr y e r ��4 -9i s '� °1 n "}<., f BE, � 4.,E 1, , a ;,a #' °q ,b Y b J r- 'z, t 97 4,1'43 '. A . County Basic �' Age 0-10...$17.01 c' $12.35 No •crisis•intervention,Minimal 4 $0 Maintenance t• Age 11-14...$18.81 " ' $.66 4.0 Not needed or cover CPA involvement,one face-to ¢r` Rate Age 15-21...$20.09 u', under Medicaid. • face visit with child per month. eft $15.774. t31 k .. $5.14 i Minimal crisis intervention as Regularly Scheduled t 1 $20.56 _ $.b6 x needed,one face-to-face visit $3.45 therapy up to 4 ' ti'.. per month with child,2-3 hours/month. '1- r rcontacts per month ri 1 '/: ,t $23.99 $.66 $17.48 t _k5_,,,,::',. $19.20 $10.28 . ," `' Weekly scheduled'' Occasional crisis intervention as 2 $27.42 $66 therapy 5-8 hours a �`, $4.9'?', needed,two face-to-face visits { with child,2-3 contacts per '1 month with 4 hours of r .> month hh. group therapy. ,` 2 / $30.85 •$.66 $20.91 ' -------- t a $22.62 $15.42 ,,i, Ongoing crisis intervention as , , Regularly scheduled �� iii it multiple 3 $34.27 $.66 needed,weekly face-to-face sessions,can include $6 50 .E visits with child,and intensive s °= coordination of multiple more than I person, x i.e.family therapy,for r services. , 9-12 hours/monthly. , 3 r.: 3 1/2 $37 69 a $.66 't-= $24.34 ------- 4 1 i $26.05 d & Ongoing crisis intervention as o. r.t4 , Congregate needed,which includes high " ° $41.13 • $.66 level of case management and Negotiated Negotiated Care T € -, g a . Drop Down CPA involvement with child and provider and 2-3 face to face Ai contacts per week minimum. `, f ,s -'ifi�"k 2y. 9� . ,k .ft�} �'�'r-fF' �} "4-',11 ,141--%,'-.", • S ..sn 3 h1�9§, �' : T+ Assessment/ FiN Emergency ': $27.42 '' x. $.66 .4i $19.20 r Level Rate 0 CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 11�day of 6 , 20 by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County,"and Hoeft, Kimberly, whose address is 720 E. 3rd Street, Eaton, CO 80615, 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 July 1,2015, 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. 0ZP 1 66; kiS-4 /1/L 0760-3°Wc2 CWS-7A Individual Provider Contract I Revised 6/2015 /b —#7—/� 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 he 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 t. 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, tires, 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. §8-17.5-102(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 6/20(5 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. 0. 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 he in writing signed by both parties. S. Neither party to this Agreement shall he 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. d,dr.44,4) Cam( COUNTY: ATTEST: v• ' ,k BOARD OF COUNTY COMMISSIONERS Weld t lerk to the Board WELD COUNTY, COLORADO ,GL�!By: Deputyjerk to the Bo arbara Kirkmeyer, hair 072015 APPROVED AS TO SU T Ele t d Officia or Dep. NTRACTOR: Hoeft, Kimberly 720 E. 3rd Street Eaton, CO 80615 By: ?if?//C ontractor' or •esignee's) Signature , and Date By: Contractor's(or designee's) Signature and Date 0.249/5-30W°2OD) CWS-7A Individual Provider Contract 9 Revised 6/2015 l--1 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 Hoeft, Kimberly, hereinafter referred to as. "Contractor." GENERAL PROVISIONS 1. 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# 1603004. These services will he 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. ?. 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 I I Revised 6/2015 ._> _ .4._.,. _. .._......... ....ate,.. .� ,. v. ... . _.. ,. .. .,,®. _... .... _ Y. ¢n 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. 11. 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 l2 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. }}. Flow often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? i P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? T . Flow much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera. 'services needed to address child's individual needs •er 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 O Self-injurious Behavior Select One ❑ Substance Abuse Select One O Presence of Psychiatric Svmptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ Emancipation Select One 7171— Eating Problems _ Select One ❑ Boundary Issues Select One ❑ Requires Night Care Select One ❑ Education Select One O ; Involvement with Child's Family Select One Exhibit B to the Additional Provisions 13 Revised 6/20l4 Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) ' 7-a-,1"•1;•u. 3 6'a.al ';;L: ;, -'..,-: ',./;;I'::'.;:,.,4',7".::::.: /j!'!„,,,,-,"')�� 3�. t„ K a y"r r 3' ,, +» Y'4kY$=4r 7 d k �Y k ,1 g $C bP' S �" '� ' a *�y� tt 4r"4 � "`�T - 9F df, 2 �: � � f p;d+ 3� 3 d 0 • 4A` .'` ,5a a v 4.; ryj } ! 1 A h 1 ' s'�F` e&m@,4 tF t ! Vc">ak?t0. 1 9 [fiyT r xp J �� - 'i }t dt1,2-":1p,-.7 .4,,t Yn 9 `�ct 4 �G Y ,, ,s3$+. `Jir„ k' F"'fM t ryf,"�i�'�. xez .ry y rii,.,,,,!,;:ii:,..,,,,,-ix7.--iii.-.,,:..47.7---47,. ..;,,,.0 N �.. Ravki t '�.k -s ` 3 ,i,4;,.'„,-.1;:.:,:.,,,,.,:,:::-,,,ii,;,-.4 ,....t i, ) $ ., , ..;.,.,,,,i„,,,,,,,,,,, ,, 77:,!: -1q i v? )k.V''�S i '� �, Ott ' '� .L. a a, '..�H V,, -s � ex , Lev‘,.,-- w. t x d n d °?ro u, fi s r'9 P,',4, •'';�',. fi^w- r'fir .. ,T r*. ,� �._'lf , x� . t � ... ^- ��.. r.. �as= . . '- "'�� ....,-�:≥ �c;r�apt W. � �, �-° w - r,�:; � � _:5 �� C �_5:,s�iw County Basic Age 0-10...$17.01 iintervention. n $0.00 Maintenance Age 11-14...$18.81 $.66 No crisis intervention. Minimal Not needed or cover CIA involvement,one face-to- Rate Age 15-21,..$20.09 under Medicaid. 4 face visit with child per month. ' a $15.77 �'- $5.14 f- '. Minimal crisis intervention as ` Regularly Scheduled $3 a5 1 $20.56 �,''3, $.66 needed,one face-to-face visit therapy up to 4 per month with child,2-3 3 hours/month. 4. contacts per month - j I '/: $23.99 s $.66 I $17.48 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 4. 2 $27 42 5.66 needed,two face-to-face visits therapy 5-8 hours a $4.97 k with child,2-3 contacts per ,' month with 4 hours of month group therapy. 2'/: $30.85 $.66 $20.91 '* 1 '' $22.62 $15.42 ,r Regularly scheduled Ongoing crisis intervention as - `: • weekly,multiple 3 $34.27 1- $.66 ;,� needed. weekly face-to-face sessions.can include $6.50 ' visits with child,and intensive P more than I person coordination of multiple i.e. family therapy,for Aiii services. •x' 9-12 hours/monthly. k' 31/2 $37.69 $.66 $24.34 "' a $ $26.05 i' e x Ongoing crisis intervention as "' needed.which includes high ... Congregate Care $41-13 , 5.66 level of case management and Negotiated �: Negotiated Drop Down CPA• involvement with child and ,--, provider and 2-3 face-to face 3 contacts per week minimum. .. . .,� .h -firV.;,-,-;',:'17.;`,...;--m i az.t - l"•»' w Assessment' t. r' Emergency 'J $27.42 5.66 $19.20 ' Level Rate - r w; CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this �'�day ofat:L-6242 20'j , by and between the Board of County Commissioners of Weld Count on behalf of the Weld County y, Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Irwin,Jeremiah and Kasi, whose address is 4544 Sunshine Circle, Loveland, CO 80538. 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: I. TERM: A. The term of this Agreement shall be from July 1, 2015, 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. - �4A ' /5-c30V02-C71-1 CW'S-7A Individual Provider Contract 1 �i Revised 6/2015 /O 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 he 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 retlect 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. lii. 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. §8-17.5-102(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 tile 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. ` ' �C COUNTY: ATTEST: d� �: / `" BOARD OF COUNTY COMMISSIONERS Weld nt Clerk to th Bo d WELD COUNTY, CO RADO By: Deputy erk to the Bo arbara Kirkmeyer Chair OC 0 7 2015 APPROVED AS TO SUB , G� � E Lb`� e' =• Officia or Depart RACTOR: Irvvin,Jeremiah and Kasi 4544 Sunshine Circle Loveland, CO 80538 By: „4 1,t9 '4 3.541S-- Contractor's(or designee's)Signature and Date By: ontractor's(or/designee's)Signature and Date OtO/ 2 (�'J 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 Irwin,Jeremiah and Kasi, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1644260. 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 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. 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 he 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. 11. 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: Select One Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. Ti. How often are thera. 'services needed to address child's individual needs .er 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 ❑ I Stealing Select One ❑ Self-injurious Behavior Select One Substance Abuse Select One ❑ — Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One J ❑ 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 Select One complete the Medically fragile NBC) ❑ Emancipation Select One ❑ Eating Problems Select One ❑ Boundary Issues Select One ❑ Requires Night Care _ Select One I ❑ Education Select One ❑ 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) �ns-a y,` a -6r'�tf4' x� ^a-z x "r$ , .4..-.'x :r• .' • s ' ` ' + � y �ki'4 P `` rt ',F,-;°.,i .",--:,,,,,,3,1,-. 1! +,ia? Atk,•-,,".,,.-. .. .»�s4 � �� '''1-:'''.:_'''''',;.:)� i '� it'��,�Y I .Ly ' �-E �[ �rip"-nrF� G�' � art,, t Y� a 4'� ' > � 11 s i. +Y. •',...?.S`::-.' I �' �` ..a ;. y • `' r .: I -,4 " "f 1�f f 3 - a k „k i 3 S�i ;'vr -� -'1,-0, tea" .,,si .t L "> �d,�,"�s �xa;� i3�i�s�#''�� 9'�;9 ej,-;:.i=,• '"' � „' � � Ye ,r•,,444.,,,,,,,..4.,,t1-1 � �! .`,_.. <. . `,1aa k �. .'-1,-, •�a io§•:, .v�ss:6k ,3 -<'aw.. ::.;::'tn.,uar 4 $12.35 a',riCounty Basic Age 0-10...$17.01 $0.00 $.66 No crisis intervention,Minimal c: sa Maintenance Age 11-14...$18.81 Not needed or cover x, g CPA involvement,one face-to- +r' Rate 'r` Age 15-21...$20.09 under Medicaid. : face visit with child per month. atm $15.77 $5.14 Minimal crisis intervention as t $20.56 $.66 • Regularly Scheduled r- S3-15 ,,,Ineeded,one face-to-face visit therapy up to 4 , . per month with child,2-3 • hours/month. w d contacts per month ) $23.99 $.66 Em 1 $17.48Ei " ^' '', $19.20 al ; $10.28 14 -a Occasional crisis intervention as Weekly scheduled 2 l'''',4 $27.42 : $•66 I needed,two face-to-face visits �• �• therapy 5-8 hours a $4.97 4; ' month with 4 hours of17. 411 with child,2-3 contacts per E fl- 4 , month group therapy. n. 2'/z DM $30.85 kit $.66 $20.91 $22.62 $15.42 m t ' Regularly scheduled ;y Ongoing crisis intervention as , weekly,multiple t•4 needed,weekly face-to-face ,_ 3 $34.27 $.66 ,• sessions,can include $6 50 �' visits with child,and intensive a more than 1 person, „ tSco,i,,,,:f„; , coordination of multiple ,1 i.e.family therapy,for r l services. 14 9-12 hours/monthly. 3 U2 $37.69 ra, $.66 $24.34 ------- ---- 1siti E $26.05 r 4 Ongoing crisis intervention as t needed,which includes high _ F Congregate - 1y $41.13 fey, 5.66 level of case management and r� Negotiated Negotiated �. Care 'r y �W: CPA involvement with child and + , Drop Down s. b- * provider and 2-3 face-to face c, 01. x, ik s , � contacts per week minimum IIIIIIMar . .,a. '>:3�' .e.ltj .a. Bra i'm..,`vnig * R w1..r to-n `. i R v._- 14:',I Assessment/ ti- e Emergency ', $27.42 $.66 � $19.20 • 4..-- �,_ V a Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 of--)6ett,ii 4) 140Z-0 • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 7day of 20 ,by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Kirchoefer, John and Erin,whose address is 2224 Scarborough Court, Fort Collins, CO 80526, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015,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. U. AGREEMENTS OF THE PARTIES: A. Contractor agrees: I. 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. 02)0/5 .649202°2- • CWS-7A Individual Provider Contract Revised 6/20(5 /D - 7- /4 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. I. 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 62015 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: I. 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 II. 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. Ill. 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. 1. 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. §8-17.5-102(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. [f 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 (I 8) 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. 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"� x s � �1 4,�$�� 'w �i^°��x� - '�� 'g � '�+� �i i ��' 3 .� � �: �e� ryt r"A BL x , a t Y z� A '€r:a a�1'''J z 'hY�- �1a � 3 s^�'�'�a��w�;:?�'k<�g₹�� ..w� 9r^ YF9�."y�'P�$�'fs'f2�s�F"��`g�V��{�}�� ip� �-e+e��.[y t � .s ia,�'�'�w� s,� f �F� �+�. qt;�' �i$ __ � ,—: t'� +�N� _;,a t 3,. u ��'r,Sr a s `'�"�S ;s �%�§ a' � � -'"�+ �� z,� �� t _K s f a'5 0.� �Y .a i r��t ti�� ; � ,�. � c, ,�„ ��. ��, .r.: ^'°" : ,� c:,��. ,,k�., -„�h. ,�L:'z�� : ��.��3a�� J 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 Kirchoefer,John and Erin, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated 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# 1631599. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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 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. 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 (FID0S). 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: I. 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 FID0S. CWS-7A Individual Provider Contract 1 1 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. I I. 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. N. How often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? P4. How often does the child require special and extensive involvement by theprovider in scheduling Select One and monitoring of time and/or activities and/or crisis management? P5.flow 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) Select One **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. T1. How often are theca• services needed to address child's individual needs .er NBC assessment? Select One NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment Assessment Areas: i 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 Enuresis/Encopresis Select One 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 Select One ❑ complete the Medically fragile NBC) ❑ 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 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) +� '''''l t t Y . ,......',7,2'.k.''' ,''.''t,'''''''q 'r ,''Pr . ,,',4„'u'_ x z g h �$r ' �+ ' s: a a '1 «3 t r r .y '.is t , —„! i:4-�.,.. £ P .ka .s'''7,`' s ..O "ds �a �#�+ ti;4 � ' � `�` I�;�' � �-vtt3 . ,, s �` e � �1�1160 v l`s t u V' 6m`s ��, Y ,t t s / ,.1 it ,ke s v w { F ','F.;''''17`., ,`*",�,� k..;,,, >t yi,1,t,. ;x� �9 ,, fir a ' a .-.',i.-',,, 424,,,',;:- ...1.,".;-.-,:',t ,_,,. .,..'1:-:.:,..L.,..., # , H s -4'.'''.'"*".$ �, i" ; ., _ 1-\:,, a• m 1''''' . 9W` '; .: ..,f. ,qt's,. 'r,-..4S .._:,k41,e: °'`, $12.35 ._ County Basic Age 0-10_.$17.01 1' $66 No crisis intervention,Minimal - $0.00 �f Maintenance r.,, Age 1 1-14...$18 81 Not needed or cover v.j ' a' CPA involvement,one face-to- - Rate !, Age 15-21...$20.09 -`, under Medicaid, lace visit with child per month. -,„„..:.- $15.77 $5.14 ; ' `- Minimal crisis intervention as - Regularly Scheduled i $20.56 5.66 needed,one face-to-face visit 4n 1., $3.45 therapy up to 4 ;- "i s per month with child,2-3 hours'month. t :` ,` contacts per month I % $23.99 z,. 5.66 ', $17.48 �. , 1a $19.20 $10.28 r Occasional crisis intervention as Weekly scheduled c 2 �` $27.42 7p $.66 needed,two face-to-face visits M J therapy 5-8 hours a F $4.97 with child,2-3 contacts per 4month with 4 hours of t',•.:1 month group therapy. 2'% „t 530.85 5.66 $20.91 a $15.42 1 c'. $22.62 sd ', ;;: 3 Regularly scheduled b N • Ongoing crisis intervention as weekly,multiple `" needed,weekly face-to-face 3 °: 534.27 $.66 sessions.can include $6.50 visits with child,and intensive - ? more than I person, coordination ofmultiple i.e.family therapy,for N ; services. '. ,,, 9-12 hours/monthly. ,, 31'2 $37.69 5.66 $24.34 i=<: t�. $26.05 s V Ongoing crisis intervention as 4 ° '' needed,which includes high Congregate ": Care $41.13 5.66 level of case management and Negotiated :w Negotiated ' CPA involvement with child and �,r Drop Down ' i W .. , provider and 2-3 face-to lace contacts per week minimum. iN74- _,,,v, '-';'-'.,-$ V..�5 .�R s�ir �F, 4 ..� ��4ar<.., rte— 'v'<. �, r$�—`-'`,�.fi�f ..,�t �...t. _.. "zt,,— ,-)1,,,,,,.., Assessment/ ' Emergency 'i" $27.42 ;f. $.6b $19.20 �f Level Rate . CWS-7A individual Provider Contract 14 Revised 6/2015 eer- ip ja2-/e) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this day of Leta , 20/5, by and between the Board of County Commission rs 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 Kliewer, Pamela and Christopher, whose address is 10473 Taylor Avenue, Firestone, CO 80504, 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: I, TERM: A. The term of this Agreement shall be from July 1,2015, 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. eC /'f -/ ,,to /5-3020201 03)/ CWS-7A Individual Provider Contract 1 / Revised 6/2015 /o /� 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 Z Revised 6/2015 w .ot- rrwr t 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 cRevised 6x'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 F-Verify program or the State of Colorado program established pursuant to C.R.S. §8-17.5-102(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 612015 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 he 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 he 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. GGll ,�,,��,,// COUNTY: ATTEST: di� GsO'eik BOARD OF COUNTY COMMISSIONERS Weld nt Clerk to the Boar WELD COUNTY, COLORADO By: Deputy lerk to the Boa arbara Kirkmeyer, hair OCT 0 7 2015 APPROVED AS TO SUBS Is La Ele d Offici 1 or De rtm' `► p �NTRACTOR: Kliewer, Pamela and Christopher 10473 Taylor Avenue Firestone, CO 80504 By: Contractor's(or designee's) Signature and Date / By: Con ctor's (or designee's) Signature and Date o1a/6"—�3 a 69-3) 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-7 A 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 Kliewer, Pamela and Christopher, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1587944. 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`11 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 a � 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 1. 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 I Iuman 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. PL How often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? P4. Flow 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. Flow often is CPA/County case management required?(Does not include therapy) Select One **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 sameprovider. T1. How often are thera• services needed to address child's individual needs •er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 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) r ," Za<� ''':-"..14..,„14-e':,,,',',#74,.' � ,�7 ?..4..i.-..a 5 3£$ N°t€ ux� 1, y 4 ar ii '� - ,,,a yleY n, r? 4� ,0A. 'a ' .k . Alii...,14:-:14 �-f-1 r c 't 4- 4 v.-Az ,- a s i, 3 v s '.' ' I`i-i ' � x ,; f ,47 r ) s ` iq _a ft.411 , <.'°� za-3.'� 1 a 4 r ',^ of �' ,C1,:.;J,,,-..�p a q "` ₹a .h.. '. ( 3 F a i �`ar ,, a� v 4 k n S�,r- r!i r'^ :k�?at +1S ;4.4-R-1:144,0,!'4 any# ,� 3 + 4.-.V-- FWill �r � ,�. 1 '" � - ,,, .. 3. t yea k s y�.„r .', ii,...„-,-;::_r„..„`', r, oar ^�o , e s rol' s. " 1 b2 k.` �� t, i 344 f 3'.:471;, "�" srr y 'PaG H m ee7rer"�'` a .-P- ° ;4.. ,' t + � o .,,,-. 1? a z ��ri.y t i '*' .a��"'�.3d41 ' ;«"' 4:1:„...-„,' ,1:7,(,,t,. se} County Basic Age 0-10...$17.01 $12.35 $(1.00 'i,x 5.66 No crisis intervention.Minimal Maintenance Age t I-14...$13 81 Nut needed or cover ' CPA involvement,one face-to- rr Rate Age 15-21...$20.09rt ii- under Medicaid. c Vim. N face visit with child per month. ' C $15.77 t..4 $5.14 . ..,. '1"-.`„ Minimal crisis intervention as $20.56 r $.66 - needed,one face-to-face visit cy Regularly Scheduled $3.45 therapy up to 4 n.: per month with child,2-3 hours/month. contacts per months 1 'A $23.99 5.66 $17.48 T. : $19.20 3. $10.28 q "' Occasional crisis intervention as Weekly scheduled 2 $27.42 $.66 thera y 5-8 hours a z`i-i' $4.97 =. =,a needed,two thee-to-face visits P _: with child.2-3 contacts per " month with 4 hours of `� month group therapy. 2'{� $30.85 5.66 $20.91 $22.62 $15.42 Regularly scheduledFre 41, 1 V Ongoing crisis intervention as weekly,multiple 3 534.27 $.66 needed,weekly face-to-facei. sessions,can include $6.50 visits with child,and intensive more than I person, coordination of multiple i.e. family therapy,for .,tAi; services. -. 9-12 hoursimonthly. �a 3 l 2 $37.69 $.66 S24.34 r:,,fir -, $26.05 4, 4 Ongoing crisis intervention as Congregate needed,which includes high Care S41.13 $.66 level of case management and .t, Negotiated Negotiated c. CPA involvement with child and Drop Down ,-_ = provider and 2-3 face-to face t a contacts per week minimum. r- „a''. .r4 ''''4,447::,f16,404.,',. ! ri rs„�. .� cF`, r -t. r ." "3 ' , 4 M' "' 4.gyp' ' Assessment/ liv EmergencyVi $27.42 ' 5.66 519.20 ., `=` h Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this day of •1\ , 20 6, 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 Korby, Stephanie and Trenton, whose address is 3105 70th Ave, Greeley, CO 80634, 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: I. TERM: A. The term of this Agreement shall be from July 1, 2015, 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: I. 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. AIS/k/A o CWS-7A Individual Provider Contract ( evi 6.2t) Revised 6/2015 ...;4.... N!✓ y..�.n..,,.._ 8.'x'snak3-ee. anv/.r'smra ^awt"pfia 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 612015 4,t xr .:max=^,smvt v+ wwa�r₹wrrk.ara 2 401.0.4,; ;•mom' r,,V,M '+kRP,Mv,.n.•F.xasr, a04^44, 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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 ,. A7 ,tap .;, ... .. rsrs 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. §8-17.5-102(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 v WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. _, ` C� COUNTY: ATIEST: G ted411/ v• •cde BOARD OF COUNTY COMMISSIONERS Weld C unt Clerk to the Bo rd WELD COUNTY, COI RADO By: Deputy Jerk to the Bo Barbara Kirkmeyer, hair p y ��••�,,,,,, y OCT 0 7 2015 APPROVED AS TO SUBS ; r'.�' �`�. Ele e Official sr Departm: !�� 4C2 ACTOR: Korby, Stephanie and Trenton 3105 70th Ave Greeley, CO 80634 By: #- Contractor's (or designeeure By: Contractor's(or esignee Signature and Date oZo/e.T L3 a (02 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 Korby, Stephanie and Trenton, hereinafter referred to as, "Contractor." GENERAL PROVISIONS I. 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# 1659973. 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 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. CWS-7A Individual Provider Contract I0 Revised 6/2015 �. .. . . v 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 I t Revised 6/2015 g'"+✓ r^.Z: :_„+A'n 40V0,0 read:'i;T ^f"+vii% tn+^T aait'h - +1"*W404%3'40,"msx 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Ilandbook which can be accessed through F1DOS. 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. 11. 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: Select One Therapy:Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. i 71.How often are thera services needed to address • individual needs er 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 Substance Abuse Select One Presence of Psychiatric Symptoms/Conditions Select One Enuresis/Encopresis Select One 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 Select One ❑ complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 6/2014 . ' Mit'0%....WyhYJ.4(.rhl^U 'R'.,, Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) LEVEL OF CHILI) AD\II`rISTR111NF ' ADMMI\ISTRVIIVF \1 DICA '' RI:SPI"1'E SERVICES NEEDS SERVICE NIAIV'T'L\�\\CE 11-AINTI:AA's\CE Level ll Rte Dail) Rule J.E. tt -_ $12.35 County Basic Age 0-10...$17.01 $0.00 No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover CPA involvement,one face-to- Rate Age 15-21...$20.09 under Medicaid. face visit with child per month. $15.77 85.14 Minimal crisis intervention as Regularly Scheduled I $20.56 >''' needed,one face-to-face visit S3 I' therapy up to 4 per month with child,2-3 hours/month. contacts per month I ',, $23.99 $17.48 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled w {' ' r' needed,two face-to-face visits therapy 5-8 hours a S4.9-7 with child,2-3 contacts per month with 4 hours of month group therapy. 2 S?u R= > $20.91 $22.62 $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple t needed,weekly face-to-face sessions,can include $6 Sit visits with child,and intensive more than I person, coordination of multiple i e.family therapy,for services. 9-12 hours/monthly. 3 I!2 s ,, 5 ni, $24.34 ----------- -- $26.05 4 Ongoing crisis intervention as0 Congregate needed,which includes high 1 "" level of case management and Negotiated Negotiated Care Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. Assessment/ Emergency )" t' $19 2() Level Rate CWS-7A Individual Provider Contract 14 Revised 6,'2015 1*oZ/at INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this /71-11' day of , 20/;) , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Lind, Patricia and Dalby, Katherine, whose address is 1611 15th Ave, Greeley, CO 80631, 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: I. TERM: A. The term of this Agreement shall be from July 1, 2015, 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: I. 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. eC 0.7-0/0 -c50202.0.2-(z5) CWS-7A individual Provider Contract I Revised 6/2015 /0 ` 7' 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. 1 I. 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 CANS-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: I. 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. I-I. 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. §8-17.5-102(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 1., 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: div W, BOARD OF COUNTY COMMISSIONERS Weld ou ity lerk to the Boa d 'WELD COUNTY, CO ORADO By: ‘litr ")g471A/4"-- Deputy erk to the Bo arbara Kirkmeyer, Chair OCT 072015 APPROVED AS TO SUB • NC E: ed Officia or Depart (en ea' t$61 %E' �• CTOR: `�'" ►•.... � Patricia and Dalby. Katherine 1611 15th Ave Greeley, CO 80631 By: Contractor's (or designee's) Signature and Date Bv: , '- Contractor's nature(or desi nee' Si g g and Date oZo i5L5a202c2 62 CWS-7A Individual Provider Contract 9 Revised 6/2015 11 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 Lind, Patricia and Dalby, Katherine, hereinafter referred to as, "Contractor." GENERAL PROVISIONS I. 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# 1658999. 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`" 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 I I 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One "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. T1. How often are theras services needed to address child's individual needs .er 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 El Stealing Select One El Self-injurious Behavior Select One ❑ Substance Abuse Select One El Presence of Psychiatric Symptoms/Conditions Select One El Enuresis/Encopresis Select One El Runaway Select One ❑ Sexual Offenses Select One El Inappropriate Sexual Behavior Select One ❑ Disruptive Behavior Select One El Delinquent Behavior Select One ❑ Depressive-like Behavior Select One El complete Needs-(If condition is rated"severe", please Select One complete the Medically fragile NBC) ❑ Emancipation Select One El Eating Problems Select One El Boundary Issues Select One El Requires Night Care Select One El Education Select One ❑ 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) sy f: e rx 'e , ,v t :*t°f -",,-',.,';'-'714`-:'-'5I-',1,tw ? ,,•,,,,,,," ,,, *-r f � r , 5 C'rth'f 1,', r. . N' $12.35 County Basic ,; Age 0-10...$17.01 $,66 ` No crisis intervention.Minimal $0.00 Maintenance ash, Age I I-14...$18.81 /�' ' Not needed or cover /,..!,,i;:„,,,* • CPA involvement.one face-to- Rate Age 15-21...$20.09 ; under Medicaid. 6 face visit with child per month. $15.77 $5.14 i'4"4,, Y Minimal crisis intervention as x; Regularly Scheduled '- 1 $20.56 $.66 needed,one face-to-face visit * f' ; $3.45 4 therapy up to 4 , per month with child,2-3 hours/month. „v contacts per monthF= l %2 `x? $23.99 a $.66 z $17.48 : 1r. Rf $10.28 $19.20 �'- 4yg Occasional crisis intervention as weekly scheduled . 45y 2 b^ $27.42 $.66 yN, needed,two face-to-face visits 1' therapy 5-8 hours a $4.97 `' with child,2-3 contacts per month with 4 hours of month group therapy. . 4. k 2'/2 $30.85 $.66 n $20.91 ;r51. $22.62 sx- $15.42 Regularly scheduled Ongoing crisis intervention as x, weekly.multiple t needed,weekly face-to-face p 3 $34.27 $.bb sessions.can include $6.50 ;r visits with child,and intensive y? more than I person. 1:x coordination of multiple / i.e. family therapy.for ., ... ' services. n�, 9-12 hours/monthly. 1.Z ';,Y4 31/2 $37.69 5.66 $24.34 i rN x`144 $26.05 4 -s Ongoing crisis intervention as • y needed,which includes high v y Congregate ,`x• r $41.13 *r''. $.66 '*' level of case management and , Negotiated t Negotiated Care •'. n, �'. rxt v-44 Drop Down x,r t 114: CPA involvement with child and p ' ,,„ provider and 2-3 face-to face r, E.� l <_ contacts per week minimum. v r ",: y y'° `r,f r '�p i 2 ,u: '}''G� /:f 4 +,y L iR!b 1'' `7 ;n" f u"Y P"k ,''''f''''!''' 5.4 H{{v 4 ei f"fiW'f�a ';',EfZ i .. / ,„n s��r�"rik ...r. ,...,,i-ik rr Y.,`. t om, .i . r,,,:'...A,,... T r,,,, '� ..,,„,if(A'I, ". rr r , Assessment/ o: 4 Emergency $27.42 .�.ry $.66 $19.20 { ; 'r Level Rate >N 51( cws-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this a' today of , 20 by and between the Board of County Commissioners of Weld Cou t , on b half of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Miller, Linda,whose address is 2034 Birch Ave,Greeley,CO 80631, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015,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. Ge: Acs tip/6-1-101- 62 6 CWS-7A Individual Provider Contract Revised 6/2015 1D-7- t�� ..53.,•}• few' .+y&•.:,: .3". 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. §8-17.5-102(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: I. 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 62015 1.4,e.H4VD, IA wN, ..4 e. :AWSIE,k�»."`°to A- .`.k WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: j 6 •'� BOARD OF COUNTY COMMISSIONERS e o r Weld n er tot WELD COUNTY, COLO ADO By: Deputy erk to the Bo arbara Iirkmeyer, lair OCT 0 7 2015 APPROVED AS TO SUB ANC IS La Ele d Officia or Departn nt /�•� ,.`t��=� CTOR: Miller, Linda 2034 Birch Ave Greeley, CO 80631 '1/YY (!< By C.• '•ctor's(or designee's) Signature and Date By: Contractor's (or designee's) Signature and Date o/c 3 a fib) CWS-7A Individual Provider Contract 9 Revised 6/2015 .u,omwe 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 Miller,Linda, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1628214. 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 ,�.� . : r . ,: C. Placement serviee reimbursement shall be paid from the date of piac�rnent up to, but not including the day of discharge. D. �I�ranspurtation reimbursement shall be for visitation purposes on(y. If inedical transportation is needed, Contractar will arrange reimbursement through Medicaid. �np 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 clathing allowance form accessed through the Foster Parents Database On- � (ine Systern (FIDOS}. 6. It is expressly understo�d 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 iheir assignees, and nothing contained in this Agreern�nt shall gtve or allaw 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. Na portion of this Agreement shall be deemed to constitute a waiver of any immunity the ' paRies or their officers or employees may posses, nor shall any partian 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 ta this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circurnvent ar replace such immunities. CONTRACTOR SHALL: 1. Attend or participate in Eamity Engagement or T'eam Decision making meetings, if requested by the Department. County staff shall notify the Cantractor of the dates and �� times attendanee is requested, � 2. Request a staffing if considering giving notice to remave a child, except in emergency situations. These requests shall be made through the child's caseworker andfor the Contractor's Foster Care Coordinator. 3. Actively participate in achieving the child's permanency goal, coogerate with any contractars hired by the Weld County Department of Human Services to preserve placement in the least restrictive placement appropriate, and comply wrth the treatment plan of the child. �. I iave physical examinations completed within l� days and dental examinations completed within $ weeks of the chitd being placed with Contractor. All documentatian c�fthese examinations will be placed in ihe foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to pramote educational success. b. Immediately report to the Caunty Department and/c�r local law enfQrcement any known or suspected child abuse or neglect as set forth in Section 19-3-30�, C.R.S. 7. Maintain, access and review informatian weekly on FIDOS. CWS-7A Individual Pr�vider Contra�:t I I Revised 6120t5 ,.a, �. ��,.. �� .. , �;�.. , . � �� 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1.How often are there services needed to address ' individual needs er NBC assessment? Select One NBC (NEEDS BASED CARE ASSESSMENT)—Behavioral Assessment Assessment Areas: Comment: Rating: R 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 Enuresis/Encopresis Select One 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 • Select One complete the Medically fragile NBC) El Emancipation Select One El Eating Problems Select One El Boundary Issues Select One ❑ Requires Night Care Select One ❑ Education Select One CII 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) LEVEL OF f'T'tTTt} .1DV1INtS'I`R1Ely _, DiC` RESPITE SERVICE M 1tNI'FN1NCE MAIN FEN 11t'F SERVICES NEEDS ', r— _ - - I_«cl $12.35 County Basic Age 0-10...$17.01 y: $0.00 r,,, No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover ---------- Rate Age 15-21...$20.09 CPA involvement,one face-to- under Medicaid. face visit with child per month $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled I $20.56 ''r," needed,one face-to-face visit S'45 therapy up to 4 per month with child,2-3 hours/month. e contacts per month 1 is $23.99 $17.48 -------- _ $19.20 $10.28 '' Occasional crisis intervention as Weekly scheduled 2 ,,' - 1-' '"` needed,two face-to-face visits therapy 5-8 hours a S-1.9 with child,2-3 contacts per month with 4 hours of month group therapy. ti;.,.,,c s..,,,, $20.91 ---------- ---- $22.62 $15.42IA Regularly scheduled I Ongoing crisis intervention as weekly,multiple 3 's, ,_ needed,weekly face-to-face sessions,can include 5h.5u f visits with child,and intensive more than 1 person, coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. 3 1/2 537.69 5.66 $24.34 526.05 4 Ongoing crisis intervention as needed,which includes high Congregate 1 ;'''° level of case management and Negotiated Negotiated Care CPA involvement with child and Drop Down provider and 2-3 face-to face contacts per week minimum. Assessment/ Emergency $27.42 $.66 $19.2nIR Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 7114 day of , 20 /oby 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 Marin, Gilbert and Lazuick-Marin,Justine, whose address is 25000 CR 69, Kersey, CO 80644, 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: I. TERM: A. The term of this Agreement shall be from July 1, 2015, 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. • D20/d-,-.32"794 62 7) CWS-7A Individual Provider Contract 1 i Revised 6/2015 /0.- 14 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. §8-17.5-102(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: d4vitev .. pi BOARD OF COUNTY COMMISSIONERS Weld C my Clerk to the B and WELD COUNTY, C LORADO By: 4A-'" eputy lerk to the B arbara Kirkmeye7, Chairitg CT 0 7 2015 APPROVED AS TO S s ST•��? ��► E .cedOffic'.1orDep: ! nt ` r` cilte1 NTRACTOR: Marin, Gilbert and Lazuick-Marin, Justine 25000 CR 69 Kersey, CO 80644 By: L'% -,%► .' ` `/1 5 Contractor's (or designee's) Signature and Date By: Con act (or • signee's) Signature and at 0.20/5 —32°2 (�?) CWS-7A Individual Provider Contract 9 Revised 6/2015 1 1--1 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 Marin, Gilbert and Lazuick-Marin,Justine, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1661206. 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 4t" 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera• services needed to address child's individual needs Der 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 6/2014 1 . Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) LEN EL1 OF CHILD i * ADMIINISTRAT1%E MEDICAL 1 RI SPI 1 E SERVICE MAINTENANCE NIAINTE N.NN CE, SERVICES NEEDS * Le‘el 4xYN s e �, ' m4 a s s Daily Rate p a $ County Basic Age 0-10...$17.01 v $0.00 Maintenance Age 11-14...$18.81 $•66 No crisis intervention,Minimal Not needed or cover Rate Age 15-21...$20.09 CPA involvement,one face-to- under Medicaid. face visit with child per month. $15.77 $5.14 0 Minimal crisis intervention as Regularly Scheduled I $20.56 $.66 needed,one face-to-face visit S 3 45 therapy up to 4 per month with child,2-3 hours/month. contacts per month IV: $23.99 5.66 iir $17.48I $19.20 $10.28 1 Occasional crisis intervention as Weekly scheduled S' ' t' 5 t't' needed,two face-to-face visits therapy 5-8 hours a S4 97 kik with child,2-3 contacts per month with 4 hours of month group therapy. 2'/: $30.85 $.66 $20.91I �b $22.62 $15.42 ' Regularly scheduled ' Ongoing crisis intervention as weekly,multiple 3 $34.27 '',6(, needed,weekly face-to-face sessions,can includeSi) 50 visits with child,and intensive more than I person. coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. 3 1/2 $37.69 s hi) $24.34 $26.05 4 Ongoing crisis intervention as Congregate needed,which includes high Care $41.13I level of case management and Negotiated Negotiated Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. I , ° aill Assessment/ Emergency y2'.t.' ti nn $19.20 Level Rate 1 ray` CWS-7A Individual Provider Contract 14 Revised 6/2015 1 r INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 7ay of Cid , 20 /5", 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 Maronek, Dennis and Patricia, whose address is 2929 56th Ave, Greeley,CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: 1 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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. Cam, kf sgc,fit ,2o�5 0za 620 CWS-7A Individual Provider Contract 1 Revised 6,2015 �� ' 744 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. "1'o 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. ttt 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 Vi.,4 emeogovOnwsopop.poogmr,vs,,,,,.0 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: I. 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 ,se: .A.. ._ 4,6..0.44.4Oh Agae, 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. II. 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. §8-17.5-102(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 - t �i!k'faSds4Mh"iNx(tbX&tYiNk .. 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: I. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local)terminated for cause or default. 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. 0. 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: C/.,c %/t+h/ 'tek. BOARD OF COUNTY COMMISSIONERS Weld o my Clerk to the B rd WE I) COUNTY, CO RADO By: • Deputy lerk to the B d arbara Kirkmeyer, ,hair 0 T 0 7 2015 APPROVED AS T• SUB ' ANCE: El d Offici. or Depart le..I c /� 1861 CTOR; onek, Dennis and Patricia 2929 56th Ave Greeley, CO 80634 By: Qo 7-dyw ( Contractor's (or designee's) Signature and Date By: c / c J Contractor's (or designee's) Signature and Date • o�� o2a (o28) CWS-7A Individual Provider Contract 9 Revised 6/2015 k i+a , 4 'm�Nwl oM� TMlm^,: '-' r&eay .-e Mm ar.�as5',m,�, ,.afilfll f'r"�et *ga5n gAan G 31 ;, - - 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 Maronek, Dennis and Patricia,hereinafter referred to as, "Contractor." GENERAL PROVISIONS l. 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# 1520627. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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 luting by the Department Administrator,prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. 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. F,. 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 6i20I5 $. 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. fY 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. 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 13 Revised 6/2015 r . ... 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. Pl. How often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? P4. How often does the child require special and extensive involvement by the provider in scheduling Select One and monitoring of time andd'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) Select One **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. TI.How often are thera• services needed to address chit+'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 • Substance Abuse Select One ■ Presence of Psychiatric Symptoms/Conditions Select One ■ Enuresis/Encopresis Select One • 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 Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 612014 Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) fi S, ;X '� .. .'.• „�' ., LEVEL OF CIItLD 1D!1T1`YTSTRA YE'. ADtir'V1STRR:ATIV . fl1 SERVICE MAINTENANCE RE9PlTE 1l.%l.' 1CN,A\CE: SERVICES I NE F"0' 4. F I . . ':._,;° ..< ,,. t '•f." ' " Dail Rate I)ai(v P .: � ... s :t.. s $12.35 County Basic Age 0-10...$17.01 $0.00 No crisis intervention,Minimal Maintenance Age 11-14...$18.81 :; Not needed or cover Rate Ag e 15-21...$20.09 CPA involvement,one face-to-• face visit with child per month under Medicaid. El$15.77 $5.14 Minimal crisis intervention as Regularly Scheduled I 1 $20.56 needed,one face-to-face visit Si ;5 hours/month. therapy up to 4 per month with child,2-3 contacts per monthiii 1 ' $23.99 $17.48 — — $19.20 $10.28 Occasional crisis intervention as ,A Weekly scheduled 2 $27.42 needed,two face-to-face visits therapy 5-8 hours a $4.9' with child,2-3 contacts per month with 4 hours of month group therapy. ;, :;,, $20.91 $15.42 . — Ongoing crisis 22;62 Regularly scheduled intervention as g gweekly,multiple .3 $34.27 $.66 . needed,weekly face-to-face sessions,can include $6 5n visits with child,and intensive more than I person. coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly 3 1 2 $37 69 $24.34 $26.05 4 Ongoing crisis intervention as Congregate needed,which includes high ('are ,,l' I ` `"' level of case management and Negotiated Negotiated 4 Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. Assessment/ Emergency �' t.:' $19.20 Level Rate »»-» CWS-7A Individual Provider Contract 14 Revised 6/2015 l'` S INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 7_day between the Board of County Commissioners of Weld County,' n 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 Martinez, Stacey and Jeremy, whose address is 1149 Northview Dr, Erie, CO 80516, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. W'ITNESSETH: WHEREAS, the Provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes andror 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: I. TERM: { A. The term of this Agreement shall be from July 1, 2015, to and until June 30, 2016, or until the facility certificate/license is revoked or suspended. t f € 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 f30)days, or until the eligible children) 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. fc II. AGREEMENTS OF THE PARTIES: f A. Contractor agrees: " t, v,< I. 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. f. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed, l`1�'S-?:� Inditi ideal Pru�,ider Cpll(f l�'( 66: �d GAA c„ D�- J Revised tV201 5 ' 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. 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. ? Not to accept money from parents or guardians. K Not to make any independent agreement with parents or guardians. Q. 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. I I. 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. h. .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, t: 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. c S-? \ Individual Prav,dcr Contract - 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 belief's, national origin, or handicap, and to provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA I. IS. 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 Depattntent 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 andior 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 ('\1'ti-7 k Individual Provider Contract t Revised 6,20 15 any statute, ordinance, or regulation and the defense of any such claims or actions. m.` o 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: I. 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 p 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. Y. To pay the provider at the rates established by the State Department ot'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 he 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. t'WS-7A I mfr.idual Provider Contract 4 Revised h,20I5 I I. To invite the provider to Administrative Reviews for Children in placement. I 2. 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. it-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 ot'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 he 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 he 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 (VS-"'A Individual Provider Contract i 4,1 Contractor to assure satisfactory' performance in the provision of purchased services wider 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 y, audit yp days otter final payment ment hereunder and shall he retained and available for A 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 he 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 Clod, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to he given under this Agreement shall he in writing and shall he 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 he 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-Verity program or the State of Colorado program established pursuant to C.R.S. 8-17.5-102(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 wider this Agreement. Contract Professional shall not use E-Verify Program or State of Colorado program procedures w undertake pre-employment screening or job applicants while this Agreement is being performed. IfC'ontract Professional obtains actual knowledge that a subcontractor pertorming • 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 (v%'5-'.1 Individual Provider Contract r, 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 tails to comply with any requirement of this provision or of C.R.S. 01-17.5-101 et seq., County, may terminate this Agreement for breach, and if so terminated, Contract Professional shall he liable 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 (I R) 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; I. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal 3 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. !lave 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 1., 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 he 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: I. 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 s-7.A Individual Provider Contract Revised 6,2015" cannot be performed or ifperfomud would he 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, andior 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, ft is the express intention of the undersigned g 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 tiled in any federal or state court or administrative agency, shall deliver copies ot'such document(s) to the County Director. The term "litigation" includes an assignment for the benefit act-editors, and filings in bankruptcy. reorganizations and,or foreclosure. R. Any amendments or modifications to this agreement shall he 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 hut 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 finds not otherwise appropriated in each succeeding year. C1bs-'A Individual Provider Contract s Revised 6,201 5 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. dierA44) COUNTY: ATTEST: " BOARD OF COUNTY COMMISSIONERS Weld o nt Clerk to the Bt rd 'FI_eD COUNTY,C LORADO By: eputy erk to the B t�� +• ara Kirktney r, Chair OCT 072015 APPROVED AS TO SUBSTAa � � 1E,1,z� E.le 1 Official or Depart nt 16u- .. 1 .: ► ' ACTOR: Martinez. Stacey and Jeremy 1 149 North iew Dr F:rie, CO 80516 Contractor s (or designee's) nature and t., c By: J Co ra is or desig s) Signature an ate • C't45-?A Individual Provider Contract 9 C>20/5-3122a2 Revised 61201 IS Lc EXHIBIT A to the CWS-7A Additional Provisions for the Agreement to Purchase Foster Care Services and Foster Care Facility Agreement CVVS-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 Martinez, Stacey and Jeremy. 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. '. 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# 1649838. 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. ;. 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. t. 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 writine 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. _ WS-7A Individual Provider Contract I ) f Revised(1,30 I 5 C' Placement service reimbursement shall be paid from the date of placement up to, hut not including the day of discharge. D. Transportation reimbursement shall he 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 he approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On line System (FIDOS). h It is expressly understood and agreed that the enforcement of the terms and conditions of fi 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 arty 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. ? 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 he 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, it' 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 andor 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 R weeks ofthe 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. ('W'S-',,1 Individual Provider Contract 1 I Revised 6,?015 n. 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 andior the Contractor's Foster Care Coordinator. 10. Maintain'update medication logs on a daily basis, if child is taking medications. II. Maintain behavior observation notes as required by the level of care assessed for each child. I?. 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. y#f CW'S-7.1 Individual Provider Contract 1 Revised 6:_'111; Needs Based Care Assessment 4 10. NBC(NEEDS BASED CARE ASSESSMENT) Answers to the following ti 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 tbster care provider for the follow ine: Select One Therapy; Medical Treatment. Family Visitation; Extraordinary Educational Needs,etc as outlined s 1. in the treatment plan? 3 P2. How niter is the foster care provider required to participate in child's therapy or counseling a sessions Select One P3. How much time is the provider required to intervene at home andfor at school with the child in conjunction with a regular orspecial education plan`' Select One —_ P4. How often n does the child require special and extensive involvement by the provider in schedulin Select One and — __ _ _ monitoring or time and.or activities and or crisis management' PS. 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. 1 Al. {ow 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 I Select One group or more than one County foster child is with the same provider. T1. How often are therapy services Herded to address individual needs r NBC assessment? Select One s NBC (NEEDS BASED CARE ASSESSMENT)— Behavioral Assessment Assessment Areas: Aggression/Cruelty to Animals — "—_4_ __ Comment Rating: Verbal or Physical Threatening — ' Select One Destructive of Pro e Fire Setting —_ +_ Select One p rty,�__ — Stealing — — ._. Select One Self-injurious Behavior — ' ---- Select One Substance Abuse —.__-- Select One ` _..__, Select One Presence of Psychiatric Symptomsr'Conditions Enuresis/Encopresis Select One Runaway i-__-._—_ Select One Sexual Offenses — --___ Select One Inappropriate Sexual Behavior -- Select One Disruptive Behavior — -- ---- ____. Select One Delinquent Behavior Select One _--- ≥ Depressive-like Behavior i` Select One — — Select One Medical Needs-(If condition is rated"`severe", please _.fi—____.____ —__,—___._______ o omplete the Medically fragile NBC) Select One Emancipation I _-----..-___ Eatin Problentis !___ ' Select One Boundary Issues • Select One - _.---- -..-._. r----- Requires Night Carr ! Select One t — — Select One Education -- —_ • Select One Involvement withChild's Family I _- _--- Select One Exhibit B to the Additional Provisions I Z Revise)h:'?01-t .. I 1.1 Needs Based Care Rate"Table %%eld County Department of Human Service 4 (Effective 710It20t5j LEVEL OF CHILD ADMINISTRATIVE I ADMINICTItATUVR MEDICAL SERVICE MAINTENANCE RESPITE MA17rPi EIVANC'E SERVICES NEEDS Level Daily Rate Daily Rate Candy Rate Daily Rate Daily Rate County Basic Agee in S!"6# SI2_sa Stainteaaace Age,l ; S;8,SI b.(r No,ro e,mtervcnnon,Mmtmal SO tkt Rate Age I i.'I 420 00 t"PA IFS,olvemem,ona tare-to riot needed or eocer lace lisp with child per month. under\4rdlcatd Sic SA I I 1 mmtmai.n.tv MKT'Cult 1 as S20'h S Ili) uecolr 1 one face ua-tn c'+rot Regularly Scheduled theta u o 4 S"4i per month AIM ihdd,2_-t therapy p t .- _-_..,__�.ti ,�llInersper'nnn1le hours month SI'48 SI)'m S It)i.a al (keelson-ail rvsis'tttenerutun ac +k ekly,teituleat 2 82,12 Sob needed (AO ra{e,�,. -taxis vtsttfi tlsertpy�r-$3toul.a !S-}.V" with rhtid,2 2 ranmts`tb per month with 4 hours of k month uro ther5 ..,_ ._...—w�.-_... .._.___...... 6 t •.Ill. 510 RS S bti S2.2 02 Ongoing Regularly scheduled K gcrib..,ntersenta)nac 3 514.27 needed,werki}tact-te-face +weekly.multiple 5.00 vtstts aah child,and Intensive vest,-,n,c,can:nu Male SO ill room than I person, Cuor,Lnatnn sit snuittpk t .tatnd}therapy (OS Set'lens. .11:2 81'(t0 S.60 S24 11 S2mIIz 4 t)ngotn4 Asti tntert cilium u. Congregateneeded a ilk,a includes+matt Care Sal.IS uti level id cii,nlarragrmrnt OWNee t,mated Negotiated brnp Down CPA insolvemeru wail child and nrwtder and 2.1 Lace to lace comma e,per Attek minimum. issessmeati Emergency S ?42 S no Level Rate $i9.�(i Cb4'S-7A Individual Provider Contract l4 Rcvcsed ft 201{ t.7t4st-c 4.c72/ INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 7day of , 20/�*—,by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Means, Nathan and Lisa,whose address is 2632 15th Ave, Greeley,CO 80631, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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(rcn) 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 he 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. Ca: aSk6ii4 p20/o'er (f � CWS-7A Individual Provider Contract I Revised 6/2015 /o-- 7-/� 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 II. 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. §8-17.5-102(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 612015 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: derAlk) BOARD OF COUNTY COMMISSIONERS Weld nt Clerk to the oard WELD COUNTY, CO ORADO By: Deputy Jerk to the rd Barbara Kirkmeyer Chair CT 0 7 2015 APPROVED AS T• SU TANCIELz % �r Ele't:. Officia or rep, en a 1861 442 '4.i► *..� CTOR: eans,Nathan and Lisa 2632 15th Ave Greeley, CO 80631 By: .4%-.1". (or designee's) Signature and Date By: __ ____� - 29 - �S Contractor's(or designee's) Signature and Date ao/.-�aa�() CWS-7A individual Provider Contract 9 Revised 6/2015 3.1'1 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 Means, Nathan and Lisa, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1601788. 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. F. 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 I I 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home andor at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera, services needed to address child's individual needs .er 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 ❑ Substance Abuse Select One 0 Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis'Encopresis Select One Runaway Select One Sexual Offenses Select One ❑ Inappropriate Sexual Behavior Select One ❑ Disruptive Behavior Select One ❑ I Delinquent Behavior _ Select One ❑ Depressive-like Behavior Select One ❑ { Medical Needs-(If condition is rated"severe", please Select One complete the Medically fragile NBC) ❑ Emancipation Select One ❑ Eating Problems Select One ❑ f Boundary Issues Select One ❑ Requires Night Care Select One ❑ Education Select One ❑ 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,j G '''''''''''''''.4 r t. tiN a ;:''''I''''7 y ap '''' „G, & as f'G �` ti c{ S. el'-'.a1.k ..1Q n x%t- ^tli k.: ' * t*rs r' 7z { Ft3�t ::a '� r+a " t41..'� nr!!4ti �s ;li srI4 ''',,Z,0,4 n s r ka �x �.� :1' � re ��'�e7s Ye'r de 7�� J,a s1,11 ��kd'>& :x��s �r�a ia. �q�-de,(a as y' p ,{K r it ;,` . a?," ` tr s. i.r �" ' 4 �� P, x s„s r `+ F- ' L�ievel ' s ; f ', ,r.-: j 1.781 Ct".?, ' '2b t t. r a e.`"I' - ) } f sw s 0 ' 1'F°s' r I p r k3 _ z '- ' s-.,s ? .&«y,~ z k�`" 2 i'°�rx p, y . • fly.. a $12.35 County Basic ai Age 0 10...$17.01 { $,66o crisis intervention,Minimal $0.00 Maintenance j Age I 1-14...$18.81 \ot needed or cover CPA involvement.one face-to- , Rate Age I5-21...$20.09 e. . under Medicaid. '- face visit with child per month. $15.77 4 $5.14 ii; Minimal crisis intervention as Regularly Scheduled 1 S20.56 $.66 needed,one face-to-face visi► 53.45 therapy up to 4 /ti per month with child,2-3 hours/month.�'' contacts per month I ''A $.66 $17.48 t.. $23.99 ` i $19.20 $10.28 Ir. Occasional crisis intervention as Weekly scheduled v 2 S27.42 S.66 needed,two face-to-face visits therapy 5-8 hours a ; $4.97 with chid,2-3 contacts per month with 4 hours of rou thera ' mimth � : g P PY 2'ii $30.85 . �$_66 .. $20.91 $22.62 $15.42 Regularly scheduled k ` Ongoing crisis intervention as weekly,multiple p ' " 3 $34.27 5.66 needed,weekly face-to-face sessions.can include $6.50 visits with child,and intensive more than I person, ,i,3 coordination of multiple i.e. family therapy, for services. 9-12 hours/monthly ' 3 1x2 $37 69 $.66 $24.34 .. $26.05 ' Ongoing crisis intervention as '1';':.i7-: 4. -- • Negotiated Congregate needed,which includes high ;' Care $41.13 ; 5.66 level of case management and Negotiated h.. -- CPA involvement with child and , Drop Down ,; provider and 2-3 face-to face contacts per week minimum 4 'lli mt x Assessment/ - Emergency $27.42 $.66 $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 eo‘-x,t- c.e,t /P A&?/(1/ INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 7-71/day of O , 20 , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,hereinafter referred to as, "County," and Nickell,Amber and Jonathan,whose address is 3350 Edison Drive, West Lafayette, IN 47906, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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. oaio--3,20202- (21) CWS-7A Individual Provider Contract /0 l ,. , 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 he 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 rt s rwwr�rr r w 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form,which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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 612015 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. §8-17.5-102(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. 'lave 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. CC� �:C COUNTY: ATTEST: C1.�� '�' `� ''kBOARD OF COUNTY COMMISSIONERS Weld o nt lerk to the B and WELD COUNTY, CO _,ORADO By: 741-dtat., Deputy er• to the B d e arbara Kirkmeye , Chair 0 T 0 7 2015 APPR VED AS TO SUBST z�`�; Lti�` Eae t d Official o Departure RACTOR: Nickell, Amber and Jonathan 2227 Willowbro r West • • t I 47906 ontractor's or designee's) Signature and Date By: C tractor's (or designee's) Signature and Date c>20/ —,-301c2`2 (6O CWS-7A Individual Provider Contract 9 Revised 6/2015 � C/ 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 Nickell,Amber and Jonathan, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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 I tome identified as Provider ID# 1662207. 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 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. CWS-7A Individual Provider Contract 10 Revised 6/2015 C. Placement service reimbursement shall he 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 he 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 he 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 he 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 I t 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 hinder. The binder will he 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? ' 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) Select One **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. TI. How often are thera. services needed to address child's individual needs .er 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 1 Select One Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 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) fr r.,g »� 'J,04 " ? � a re '.,,., , .1t ,' X44 LEVEL OF k v ' i 13 fi .R-' ��,Ii) O i 4,--,41IA it*D,.^0 8"04 t o•s( ''# .'SERVICE,..,,:.,q. d e - A-,4,,,-1. •, b ` • ,,, ,,,,,t fi • i, Ear 4S�,0' "' ' r sI. .fit ri® * a. .e.d F 1��` f *4 It �,� ..1 .i(;,, '�+.�,,. ', ...'.1.-;-,4iizi . i.-iq, � .r r+ v+s y �°f ,i`�h •. ₹fi-.th� .; q t 'u �r t . asp a � � ., ��h�f'.�kv{i�# a3. �"'�A a.,`e,'.'" �� a n5't ,�'E s 7. 1w } r .- a?� �� L:- ..,,,,,,.,,,,--r ,., ';v ° '.,-"7,:t..A y ii...+1. e�'- f ( t, ara' 't t w5.,,X. � r.t, a... Y x a 'Level__ ., '$"¢`i,t ..Fy 8 i e r1 i '' r =';a :41,;- ; fi . ,.a.+. .; " ti; :t,'!. ,:. , .. O-s., . - '., welts.- " ''ink. 4 ., $12.35 County Basic Age 0-10...$17.01 ` 0 $0.00 $.66 ,': No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover Rate . Age 15-21...$20.09 CPA involvement one face-to- under Medicaid. $ face visit with child per month. ,r $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled 1 $20.56 $.66 needed,one face-to-face visit therapy up to 4 $3 45 per month with child,2-3 s,i hours/month. contacts per month 1 'A $23.99 '-'1' $.66 $17.48 -ill, y s'NS T $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 2 $27.42 $.66 needed,two face-to-face visits therapy 5-8 hours a ; $4.97 x with child,2-3 contacts per , month with 4 hours of • _ month * group therapy. 2''A $30.85 ' $.66 $20.91 A ---------- .; --------- ," $15.42 a' > $22.62x". T Regularly scheduled slOngoing crisis intervention as ., weekly,multiple 3 $31"" .,a $66 r needed,weekly face-to-face sessions,can include ' $6.50 ", ,a visits with child,and intensive i more than 1 person, coordination of multiple t;;;;: i.e.family therapy,for services. ;₹ 9-12 hours/monthly. 3 o y 3I 2 $37.69 $.66 i $24.34 0 $26.05 4 a - Ongoing crisis intervention as Congregate �. p: needed,which includes high �, $41.13 $.66 t level of case management and4 Negotiated Negotiated Care Q CPA involvement with child and Drop Down a provider and 2-3 face-to face contacts per week minimum. c h s� '�� Assessment �y V,1 Emergency $27.42 u $.66 y : $19.20 Level Rate i y' j': h CWS-7A Individual Provider Contract 14 Revised 6/2015 .t /Vc'Zi INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 17/ THIS AGREEMENT is made this day of C , 20 /,5 , 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 Oliver,Jonathon and Melynda, whose address is 1114 Micros St., Erie, CO 80516, 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: I. TERM: A. The term of this Agreement shall be from July 1, 2015,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: I. 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. Gam; itiSkF" 020/ 3a2a0T-(3;0 CWS-7A Individual Provider Contract 1 / Revised 6/2015 /0 - 7— /� 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 I. 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. I-[. 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. §8-17.5-102(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. �C�(C ...t � ee�� ,�,/ COUNTY: ATTEST: C1�� ) G: 4 BOARD OF COUNTY COMMISSIONERS Weld n Clerk to the B and WE D COUNTY, COL ADO By: i hair Deputy lerk to the rd Barbara Kirkmeyer, OC 0 ? 2615 APPROVED AS TO SUBS1 ANC ;* " El ed O111 ial or De ,rtment � , . *►-" ACTOR• •liver, Jonathon and Melynda 1114 Micros St. Erie, CO 80516 By: Contractor's (or designee's) Signature and Date �^ By: `l14 dilYtaC,L 1 ' rs Contracto (or designee's) Signature and Date g) , C1-14_641 0.20/1--,_302 Oa) 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 Oliver,Jonathon and Melynda, hereinafter referred to as, "Contractor." GENERAL PROVISIONS I. 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# 1665582. 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 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. 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 I I 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. I I. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera services needed to address child's individual needs .er 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 O Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ Runaway Select One ❑ Sexual Offenses Select One O Inappropriate Sexual Behavior Select One ❑ Disruptive Behavior Select One O Delinquent Behavior Select One ❑ Depressive-like Behavior Select One ❑ Medical Needs-(If condition is rated"severe",please Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 6/2014 1 Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) ..f,._+s ..w b,..�e,'n. .. ^•'k r; ..' "" .._ �..mt �'`",�.'y.. -..-... ,n.. .a,,,,.:::::: ,,..,: s.am.a b.:;,.-a, ..Ii-i# .,',` f: SERVICE MIAIN7 E\AN(�E RESPITE MAIN I ENANCE SERVICES NEEDS I I_:elel aa ►. ate Daily Rate a +K� -' ' `a � Daily Rate ^ ,: . ('ounh Basic Age 0-10...$17.01 $12.35 $0.00 Ntaintenance Age 11-14...$18.81 $•66 No crisis intervention,Minimal Not needed or cover Rate Age 15-21...$20.09 CPA involvement,one face-to- under Medicaid. face visit with child per month. $15.77 :: $5.14 Minimal crisis intervention as Regularly Scheduled I $20.56 $-66 needed,one face-to-face visit $'.45 therapy up to 4 r per month with child,2-3 hours/month. contacts per month I '/ $23.99 $.66 $17.48I $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 2 $27.42 $.66 needed,two face-to-face visits therapy 5-8 hours a $3.97 with child,2-3 contacts per month with 4 hours of month group therapy. 2/2 $30.85 5.66 IP $20.91 $22.62 $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 $34.27 5.66 needed,weekly face-to-face sessions,can include $6.50 visits with child,and intensive more than I person. coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. 3 1/2 $37.69 F $.66 $24.34 II $26.05 4 Ongoing crisis intervention as Congregate needed,which includes high ,,-II_I ',.o, level of case management and Negotiated Negotiated Care Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. a- ®* r �} ` Assessment/ i .. Emergency `'- P $.66 $19.20 Level Rate CWS-7A S-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this / 1 day ofaf44-e-A--), 20 by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,hereinafter referred to as, "County," and Miller, Pamela, whose address is 5151 W 29th Street, Unit 2004, Greeley, CO 80634, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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. ,c,240/ —3,102.Q. (33) CWS-7A Individual Provider Contract I Revised 6/2015 /O -'7-/5 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. I I. 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./20I5 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 (14IPAA). 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 1-Iuman 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. I-I. 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, tires, 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. §8-17.5-102(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 G.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: I. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local)terminated for cause or default. N. In addition to terminating this Agreement, in accordance with the provisions of Section 1., 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: I. 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. dirdtv1) G� COUNTY: ATTEST: �• '� BOARD OF COUNTY COMMISSIONERS Weld o n Clerk to the Bo rd W LD COUNTY, CO ORADO By: Deputy erk to the B arbara Kirkmeyer, Chair 0 j 0 ? 2015 APPRSVED AS TO UBS 'NCE: L.„,� Ele e Official •r Departm t I d 1861 1.' TOR: �`�"i „•.,, �: 'amela 5151 W 29th Street, Unit 2004 Greeley, CO 80634 By: 4I'VVZ,Pet.0r v' Sholls Contractor's(or designee's) Signature and Date By: Contractor's(or designee's) Signature and Date 020/5 —32 2 (33) CWS-7A Individual Provider Contract 9 Revised 6/2015 1 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 Miller, Pamela, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1587465. 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-Ith 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. ?. 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 I I 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education 'Ian? 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) Select One **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. T7. How often are thera services needed to address child's individual needs .erNBC assessment? Select One NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment Assessment Areas: Comment: Rating: [J 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 ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 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) LEVEL OF CHILD ADMINISTRATIVE ADMINISTRATIVE MEDICAL ' RESPITE SERVICE MAINTENANCE _, , , MAINTENANCE- SERVICES NEEDS . Level , " Daily Rate = Dat1v Rates Daily-Rate baalyRate Daily Rate?' 512,35 County Basic Age 0-10...517.01 50.00 5.66 No crisis intervention.Minimal Maintenance Age 11-14...518.81 Not needed or cover • -------- Rate Age 15-21...$20.09 CPA involvement,one face-to- under Medicaid. face visit with child per month. $15.77 55.14 Minimal crisis intervention as Regularly Scheduled 1 $20.56 $.66 needed,one face-to-face visit $3.45 therapy up to 4 per month with child,2-3 hours month. contacts per month to 1 V1 $23.99 $.66 $17.48 ."4 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 2 ra $27.42 5.66 needed.two face-to-face visits therapy 5-8 hours a $4.97 with child,2-3 contacts per ' month with 4 hours of 4T= month group therapy. z, 2 'A $30.85 $.66 $20.91 --------- $22.62 $15,42 Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 534 27 5 66 needed,weekly face-to-face sessions,can include 56.50 visits with child,and intensive more than I person, coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. 3 1/2 537.69 5.66 $24.34 $26.05 4 Ongoing crisis intervention as Congregate needed.which includes high Care 541.13 $.66 level()lease management and Negotiated Negotiated Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. Assessment/ Emergency $27.42 $.66 $19.20 -------- ----- Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT AUG 252015 FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this / day of , 20 IS , by and between the Board of County Commissioners of Weld County, o ehalf of the Weld County Department of human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Pluma, Mike and Annette,whose address is PO Box 34, Kersey, CO 80644, 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: I. TERM: A. The term of this Agreement shall be from July 1, 2015, 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 children) 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: I. 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. e.&; 1-&/6/a1A 0.49/ -L5a2e'9A (34) CWS-7A Individual Provider Contract /O 1 �� /°' 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 • 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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 F.-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. 0. 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. Cam( COUNTY: ATTEST: darif44) '(A BOARD OF COUNTY COMMISSIONERS Weld u ty Clerk to the Boa d WELD COUNTY, COLORADO By: - eputy rk to the Bo arbara Kirkmeyer, air 0171c-f• 2 015 APPROVED AS TO r UBSTANC • Sida Ele'I d Offici. or DepartmS ea. f7; �►, �.,. :�. CTOR: uma, Mike and Annette PO Box 34 Kersey, CO 80644 B YL/r Y• ont ctor's or designee's) Signature and ate By: Contractor's(or designee's) Signature and Date 0Z%&2 (3 ) CWS-7A Individual Provider Contract 9 Revised 6/2015 1. 2 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 Pluma, Mike and Annette, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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#35126. 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. ?. 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 I I Revised 6/2015 , S., 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. 11. 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. 1 How often does the child require transportation by the foster care provider for the following: ! Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment_plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. flow much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. (low often are theras services needed to address child's individual needs .er NBC assessment? Select One NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment 1 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 Enuresis/Encopresis Select One 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 Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 6/2014 • Needs Based Care Rate Table • . 4, Weld County Department of Human Service (Effective 7/01/2015) ✓�. �,.k ''.•,.,75,:,,,,••,,',f' d :m r`�,�c ' „ ,. f�. r r 7 s+f'3 a x .x x`l s r, >� ,r n �ss? m � a �s �"" "'��st ,G`�ma. �'�`I t�: Y ,#" ,� �" dh Y e 1,I, �+ t,r d f ;it ' _.x. 6"" �, sn e 'a e a .--t {.,s-a` - ,3 ��"i a+ n � 4 .,A �"{a��4 w n��.? � � -` sa� w $�. ��' -,-'--z.64-f...E ' A 9 1 u�9.a`.��R•w, �-�..!..!'-4::, :i s a`r� k z , Mrs .,� �e '1-t','1-q.,,. ' M * � :�'�#� fit+ Fyn ��.�, a'� �` 4 - r -- e.. it , 84 r r dam -, -,��" �z" a� '- a w,µ. '2 .'''''''''''4'P.;';;' s , A'N' 4-'.'.' ., c ~ C' t4' bx 'hex rya 'Fx k x; � � i^ }e ' r ; '`�d!i i 3 4 a t':Nri�',- €-k �$ `�- k` °' � k',-�,�' s `} , :r j_:' G ''�'- $12 County Basic Age 0-10...517.01 .35 50.00 5.66 No crisis intervention,Minimal ` Maintenance Age 11-14...518.81 i Not needed or cover CPA involvement,one face to- under Medicaid, ''Rate " Age 15-21...$20.09 face visit with child per month. .+ 1,!,..,f•: $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled , 1 - 520.5611.??: 5.66 $3.45 0; needed,one face-to-face visit therapy up to 4 x: # per month with child,2-3 !'" hours/month. . contacts per month :•t 1 '/2 $23.99 5.66 $17.48 a``: z' 519.20 ''7`;_. $10.28 Occasional crisis intervention as Weekly scheduled 2 $27.42 5.66 needed.two face-to-face visits therapy 5-8 hours a dig $4.97 with child,2-3 contacts per ; month with 4 hours ofp. a,, month group therapy. wer— _ _ .. i 2'/ $30.85 5.66 $20.91 - $22.62 515.42 s r Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 $34.27 $.66 needed,weekly face-to-face sessions,can include $6.50 visits with child,and intensive more than I person, t* � coordination of multiple i.e. family therapy,for S services. 5, 44 9-12 hours/monthly. 3 1/2 $37.69 5.66 $24.34 , � $26.05 it = Ongoing crisis intervention as 71 4 Congregate • _ needed.which includes high , Care 541.13 at $.66 level of case management and Negotiated Negotiated Drop Down CPA involvement with child and : provider and 2-3 face-to face t l contacts per week minimum. ..r I.a: 171 ''''''''",: t.-:-.4v a > aFf rk #t t �• Assessment/ 41. Emergency ` $27.42 �' 5.66 $19.20 Level Rate r CWS-7A Individual Provider Contract 14 Revised 6/2015 u%c /O .'°"de2 eZ INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 71 day of6 /, 20 by and between the Board of County Commissioners of Weld County,on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Potter,Donald and Amy,whose address is 4918 W. 8th Street, Greeley,CO 80634, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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: I. 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. 0/5" 3 - (35) CWS-7A Individual Provider Contract I Revised 6/2015 /Or" '7-/� 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: I. 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 __ _ .. , I I. 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 hind 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 CW S-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. §8-17.5-102(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 tile 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: I. 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: j/,,4) W ;(1 BOARD OF COUNTY COMMISSIONERS Weld C u ty lerk to the Boar WE D COUNTY, COL RADO By: gAitfa/C Deputy Clark to the Boar Barbara Kirkmeyer, hair ccT 7 2015 el S I.A APPROVED AS TO SUBST• CE:St e� d Official •r ie artm� t Head t>I6t �j p r ' i\l/A/ Director of General Services CONTRACTOR: Potter, Donald and Amy 4918 W. 8th Street Grreley, CO 80634 By: ` —11'2'111C- Contractor's(or designee's) Signature and(Date By: NN Vl\k(' 1 } \ Contracto ' designee's) Signature and Date 7 - oi3 (3 ) CWS-7A Individual Provider Contract 9 Revised 6/2015 3-.)...1_ 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 Potter,Donald and Amy, 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# 1668566. 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 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. 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: I. 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 I I 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. 11. 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 i closest rating for this child. The following seven(7)questions are mutually exclusive. I P1. How often does the child require transportation by the foster care provider for the following: Select One Therapy;Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions'? P3. How much time is the provider required to intervene at home and/or at school with the child in , Select One conjunction with a regular or special education plan? 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 andior 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) Select One **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. TI. How often are thera• services needed to address child's individual needs .er NBC assessment? Select One NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment Assessment Areas: Comment: Rating: R 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 [j Substance Abuse Select One R Presence of Psychiatric Symptoms/Conditions Select One Enuresis/Encopresis Select One I ' o Runaway Select One Sexual Offenses Select One ❑ Inappropriate Sexual Behavior Select One ❑ Disruptive Behavior Select One ❑ Delinq_uent Behavior Select One ❑ Depressive-like Behavior Select One El complete Needs-(If condition is rated"severe",please Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 6/2014 ..._ _ .. y,.. _._.. ,. ..,..._. . W .IfW ... .,5... ... ...�.......,.....M, Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) k ''''-:;,,M', � �, ,tr, '''-'.. .".•''''',;:.7.-'4,..--.7 ^t" d t' �°4141: ' M-zc rE '.td'z ' k�, ',.. , .1"ts i r 'Cr s as ed a t ,dt't- r ac �xz;� d . q �' i h''. r •j" 'ms , ¢.e < - 444,4044-1 -. i�, °4# ' �t c� :t ° ' ^. ih '6 mgr °3'„w x ? _-u34 c f� • 4"itk wc;t 4i ' ^s ;;Q• . F v` S. �.,11. `fi b a ate :: '� : i''r:';''''''-0- t - �, . -` ff`t -,S f . t - -. . '"rei,, x a - .«� .:`i,r. i., i ,s ''- z"7.--;;4'' ''.'z'''.:,:- ,4'r-'°'y°,., f w ¢ � 5k $ � ,i t u x`' " k " $12.35 ' County Basic Age 0-10...$17.01 .i°< $0.00 5.66 No crisis intervention,Minimal Maintenance Age II-14...518.81 '' i.'- CPA involvement,one face-to- Not needed or cover Rate +r r„ Age 15-21...$20 09 under Medicaid, face visit with child per month. $15.77 h $5.14 A, Minimal crisis intervention as Regularly Scheduled 1 $20.56 $.66 needed,one face-to-face visit ',f.- $3.45 therapy up to 4 i'` per month with child,2-3 ,. contacts per month I V: $23.99 $.66 $17.48 <...: ----------- $19.20 $10.28 @�"`, Occasional crisis intervention as _ _, Weekly scheduled � - 2 $27.42 $.66 needed,two face-to-face visits •h.' therapy 5-8 hours a 4' $4.97 - 2-3 � month with 4 hours of with child, contacts per n group s monthit,' g p therapy. '-'kS .µms-,,.' t- 2'A $30.85 ' $.66 $20.91 i,_'%3'..', r< h� $22.62 $15.42 iqrA f •' Regularly scheduled Ongoing crisis •intervention as 4 weekly,multiple .r needed,weekly face-to-face ", 3 $34.27 5.66 sessions,can include $6.50 ,-• visits with child,and intensive x; more than I person, ;R'' ;'o coordination of multiple » i.e.family therapy.for services. 9-I2 hours/monthly. 3 1/2 j $37.69 5.66 " ' $24.34 ': ---------- .g-V ;,, $26.05 4 `"" Ongoing crisis intervention as Congregate needed,which includes high Care 541.13 5.66 level of case management and Negotiated M Negotiated Drop Down = CPA involvement with child and .. provider and 2-3 face-to face contacts per week minimum. `!�+4"l .1:4,-7-4,e:,, r 4 f ,, . '� A'w G v t--, 3� -Ir.-r-,, ,,,, As 4371:1. esggi^ f Assessment/ "a Emergency !. $27.42 ,.' $.66 $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 .A A.,,-.L'v .e/..'.. ..P.., .. j�P�•j1.9. /D az INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 711 day of , 20/-5-, 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 Roderick, Douglas and Kelli,whose address is 3110 57th Ave, Greeley CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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. eye,: 45/101(--- 0.204 -39202c2 (3Z°.) CWS-7A Individual Provider Contract Revised 6/2015 kO,W+404.4 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services,the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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 1., 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: I. 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. 0. 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 ,00 00000 the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: dir J •-fe&O;t1 BOARD OF COUNTY COMMISSIONERS Weld unty Clerk to the B and WELD COUNTY, COLORADO By: r Deputy lerk to the B arbara Kirkmeyer, Chair VT0 7 2015 APPROVED AS T• SUB A • El t d ♦ffici orDep.! e► .=a ,;� ' �� 1861 { ��}33 ar .1 NTRACTOR: � �,►r 'Roderick, Douglas and Kelli 3110 57th Ave Greeley CO 80634 By: �... ° Contractor's (orciestnee's) S gnat and Date By. -Nt -Co-tractor's (or designee's) ignature and. Date o2v/J-3 z2a, 3 I.°') 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 Roderick, Douglas and Kelli, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 10994. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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 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. 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. 11. 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: Select One i Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often fs the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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,andror occupational therapy? Al. How often is CPA/County case management required?(Does not include therapy) Select One **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. Ti. How often are ther.• services needed to address i individual needs ser 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 Substance Abuse Select One Presence of Psychiatric Symptoms/Conditions Select One Enuresis/Encopresis Select One 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 Select One complete the Medically fragile NBC) ❑ Emancipation Select One ❑ ' Eating Problems Select One D Boundary Issues _ Select One ❑ Requires Night Care Select One E Education Select One ❑ Involvement with Child's Family Select One i 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) i.1,'1 El.O RESPITE SERVICE MAINTENANCE MAIN I EN kNCE SERVICES NEEDS Leel , ,.9,1:ry'Rate Dail �,: i)ailtR * ` —� p. a ,G,, IJttil, Rate $12.35 County Basic Age 0-10...$17.01 $0.00 $.66 No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover Rate Age 15-21...$20.09 CPA involvement one face-to- under Medicaid. face visit with child per month. $15.77 • $5.14 n Minimal crisis intervention as Regularly Scheduled al I $20.56 ti„" 2 needed,one face-to-face visit b 3 3 i 4= therapy up to 4 ' per month with child,2-3 ' hours/month. contacts per month — $23.99 3.66 ,:. $17.48 ------- $19.20 $10.28 Occasional crisis intervention as . Weekly scheduled 2 I'- "" needed,two face-to-face visits therapy 5-8 hours a $4.97 I with child,2-3 contacts per month with 4 hours of month group therapy. 2 ,.Hi ,,n,, $20.91 $22.62 - $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple $34 '- 5 needed,weekly face-to-face sessions,can include $6.50 visits with child,and intensive more than 1 person, coordination of multiple ,e.family therapy,for services. 9-12 hours/monthly. 4 $37.69 $24.34 ---- --------- _._ Congregate _ -- $26.05 Ongoing crisis intervention as needed,which includes high Care 1 ��' level of case management and ed y Negotiated Drop Dow n CPA involvement with child and provider and 2-3 face-to face r contacts per week minimum. 0 Assessment/ Emergency $27.42 s'a, $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 r.r..:.,._ . . .,.: INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this day of Ati5Dr , 20 IT", 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 Rosenoff, Kelsey and Jayllee,whose address is 591 Dakota Court,Windsor,CO 80550, 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 July 1, 2015,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: I. 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. CWS-7A Individual Provider Contract I Revised 6/2015 e &,` 020/ /o 7-7,5 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 he 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 contlict 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 6/201 5 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: I. 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 II. 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. 111. 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 he 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. §8-17.5-I 02(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: I. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,or performing a public(federal, state,or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements. or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state,or local)with commission of any of the offenses enumerated in paragraph (B)above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions(federal, state,and local)terminated for cause or default. 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. 0. 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 WI-IEREFORE,the parties have herein set their hands and affixed their seals the day and late first written above. COUNTY: -�,,` Cyr I� ' ATTEST: GI,dtIgJ �• ' `'BOARD OF COUNTY COMMISSIONERS . Weld o n Clerk to the Board WET_D COUNTY,COL RADO BY: - Deputy , erk to the B , d arbara Kirkmeyer, hair OCT 072015 40. APPROVED AS TO : ' !iii': N. pNs.s, 1*. i_ ii.)\ h c e Official r "' ��`t't"- �46.‘ 16,1 i/.., )0: , „ IONTRACTOR: 444`' ry% ✓ Rosenoff,Kelsey and Jaydee 591 Dakota Court Windsor,CO 80550 By: �? � 1-27-15Contractor' (or designee's ignature and Date By: B , 7-17-i5- & t. ctor's(or designee' Signature an ate CWS-7A Individual Provider Contract 9 Revised 6/2015 02,0/.2 (3'l) --)ti1 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 Rosenoff,Kelsey and Jaydee, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1652955. 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`"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. Et 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 I I 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 I. 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. PI. How often does the child require transportation by the foster care provider for the following: i Select One Therapy.Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? I P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? P4. How often does the child require special and extensive involvement by the provider in scheduling Select One 1 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) Select One **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. T1. How often are thera. services needed to address child's individual needs .er 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 Substance Abuse Select One Presence of Psychiatric Symptoms/Conditions Select One EnuresisBncopresis Select One ❑ 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 Select One ❑ complete the Medically fragile NBC) ❑ Emancipation Select One Eating Problems Select One Boundary Issues Select One in Requires Night Care Select One Education Select One ❑ 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) .,�'� *:4 z ' _ � tN: `s*L r�s ry: :.'7.:',5.� � �v r�g � 1, vk ^�}^ •� i r'$' '��f . r� ,: ','' ty ..,.._'4 .,w_.---,-.:'';;;-.;=',"4,!", K tic' �, '"#R`yt cq .�" ,"4" z i -,,' r • 4,ti k tst° q— 3 4r, .. t !...o h, j ::3 I- „wy A'44,i .. '',',,,--!-:',,,,,',"=1-4; i i.'4..;:'''a.` *�1'!'1414''''''''''''I v:/-*:'''' '':',' `v ,,w"'''''''''''-'444::4','" *.t n7°,T_4' ix t '� -,'444--,. l 3., -i:s"�{p '-'{ Fi, .�,f at. 1 y%� a '$ e' o- .„r .E, .rs mss- ,,,--1-'-''',„e s. r a , "+ ten ° . 'rte ,s v.. ."gar_ ' ci .',.,,,,A, ' ta g ' U "' 4s`'� dm`s > =vwg a i. �,a� County Basic Age 0-10...$1701 ;' -i $1 .35 $0.00 $.66 '-: No crisis intervention.Minimal ;;- Maintenance ?v; Age I1-14...$18.81 Not needed or cover Rate 2 `" CPA involvement,one face-to- Age 15-21_.$20 09 under Medicaid. face visit with child per month. $15.77 $5.14 ,A Minimal crisis intervention as It Regularly Scheduled 44,--f-''' 1 ' $20.56 �'.� $.66 needed.one face-to-face visit $3.45 i * therapy up to 4 Asa ` ,4 per month with child,2-3 „ hours/month. a' contacts per month I'/: r $23.99 $.66 $17.48 ` $19.20 $10.28 ` Occasional crisis intervention as Weekly scheduled W needed,two face-to-face visits therapy 5-8 hours a . r 2 $27.42 $.66 $4.97 a month with 4 hours of k with child.2-3 contacts per = iii , month group therapy. 2 A $30.85 $.66 $20.91 0 t' r, $22.62 ,, $15.42 _., F �ra`� !- Regularly scheduled " Ongoing crisis intervention as � . �= weekly,multiple 3 $34.27 $.66 r' needed,weekly face-to-face sessions.can include $6.50 visits with child,and intensive , ,E .; more than I person. .., r coordination of multiple F. i.e.family therapy.for - services. :;f: 9-12 hours/monthly. 3I'2 ,,,,,iP $37.69 $.66 $24.34 ' 44 . $26.05 4 I{ Ongoing crisis intervention as needed,which includes high 4',R( Congregate $41.13 $.66 level of case management and Negotiated Negotiated Care '," Drop Down ` CPA involvement with child and 1 • provider and 2-3 face-to face - s4- contacts per week minimum Assessment/ - �* .r--`' € Emergency $27.42 $.66 w' $19.20 '44' Eviir Level Rate Fg- ,.>'i'. t- CWS-7A Individual Provider Contract 14 Revised 6/2015 $1-76%-#4r't INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this day of , 20/. by and between the Board of County Commission 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 Rubick,Justin and Lacey, whose address is 3103 Horseshoe Ct., Evans, CO 80620, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015,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. 0,20/ -"Z07-.02a2-(88) CWS-7A individual Provider Contract 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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 =HHbava'n*t*HM,H,HHHAIHHHIMalAHR,.a,.«.. 'H., .k ......,.- .. r vc.' wapk-...., ..y WI-IEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. � :ICOUNTY: AM,M,' , dia.%) � �D OF COUNTY COMMISSIONERS Weld out y .lerk to th Boa WE )COUNTY,COLC)RAI BY __ eplity Cl o he Bon arbaia Kiriuueyer,Chair OCT 0 7 2015 APP OVER AS TO s�► � El ct'd Official r ►��, �!� ,� �� las,, 1861 .t ti ♦� �2ACTOI2: •k,Justin and Lacey `*►' 3 Horseshoe Ct. _ Evans,CO 80620 By:_ A -7I'1iIS Contras i s(or designee's)Signature and ate 01 e,,,,( eubj;c it, By:_ 71-3i 11S C,tt ' 's(or designee's)Signature and st e' �.r i t'7 JG-tAh 1'C-A— il� I t CMS-7A Individual Provider Contract 9 Revised 6/2015 ar — o2olr J‘I'&32. 1.65') 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 Rubick,Justin and Lacey, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1663770. 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 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. 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera• services needed to address child's individual needs ler 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 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) LEVEL OF CHILD ADMINISTRATIVE ADMINISTRATIVE MEDICAL RESPITE SERVICE MAINTENANCE MAINTENANCE SERVICES NEEDS Level Daily Rate Daily Rate II Rat -, , D ' :.Rate Daily Rate $12.35 County Basle Age 0-10...$17.01 $0.00 66 No crisis intervention,Minimal Maintenance Age 1 1-14...$18.81'Not needed or cover ' CPA involvement,one face-to- Rate Age 15-21...$20.09 fi under Medicaid. face visit with child per month. F' $15.77 $5.14 libi Minimal crisis intervention as Regularly Scheduled 1 $20.56 $.66 V. needed,one face-to-face visit S3 45 therapy up to 4 per month with child,2-3 hours/month. y. contacts per month I ''A $23.99 r S.66 $17.48 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 2 $27.42 $.66 needed,two face-to-face visits therapy 5-8 hours a 5-t.9' with child,2-3 contacts per month with 4 hours of Y month group therapy. 2 ''A $30.85 $.66 $20.91 $22.62 $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 $34.27 5.66 needed,weekly face-to-face sessions,can include $6.50 visits with child,and intensive L more than 1 person. coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. 3 1/2 $3 7.69 V;.66 $24.34 $26.05 4 Ongoing crisis intervention as needed,which includes high Congregate $41.13 $66 level of case management and Negotiated Negotiated Care Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. a ■ Assessment/ Ir Emergency 527.42 $.66 - $19.20 Level Rate _ 41 CWS-7A Individual Provider Contract 14 Revised 6/2015 ,t rD -4070 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this �7�day of , 20 /• T by and between the Board of County Commissionets 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 Salazar, Clara and Michael, whose address is 1269 49th Ave. Ct., Greeley, CO 80634, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015,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 isrenewed. C. f-5-ffCtli —' 020Al J3 2 (6?) 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 - ....... .. .. -.,..._ . _ ...- .., _ �. _ .,-...,.. . yam n... a�..., _ .... ..a r ..- 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof 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 he 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 he 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. IL 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. §8-17.5-102(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. 0. 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. � Cam{ �,�,/ COUNTY: ATTEST: f oddee / v� �CL�o;ok BOARD OF COUNTY COMMISSIONERS Weld u y Clerk to the Board WELD COUNTY, C LORADO By: t, Deputy Jerk to the oard Barbara Kirkmey , Chair ��` OCT 0 7 2015 .APPROVED AS Ts S :S ' � :� i El c ed O ffic•:1 or Dep!' °f'• = �� 1 1 NTRACTOR: Salazar, Clara and Michael 1269 49th Ave. Ct. Greeley, CO 80634 r.� By: s' 3 iS_ Coniracto's'(- r designee's) Signature and Date By: Contractor's (or designee's) Signature and Date (30272 -(39) 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 Salazar, Clara and Michael, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1663774. 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 I I 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 I. 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. rPl. Flow often does the child require transportation by the foster care provider for the following: Select One Therapy; Medical Treatment: Family Visitation: Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? I P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? P4. Flow 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. flow often is CPA/County'case management required?(Does not include therapy) Select One **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. T1. flow often are theta. services needed to address child's individual needs •er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 612014 Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) e bk�•i '.7 1+ ', d t t ,�,w »fie 3 s'S,7'!. a +';+ nA a.., rs r7. to y"',FM' '4._?..!. ' �?,r s. h 44:, :' i < :s t a �° ,� :: O,1t r W ¢ rfiw "y ° ,b a a " `9$g a6 e. t z. :, x° E '"��'{�� .y„� st' a�t � fi� � > i��,�s° y "�'. � �v� �� r �� "tHiprt �S�� k1,---e:/;',4—, 1$1.,..40,-,,Y.--=..-, mac � ,/�- � . a t s a,s d �` � y€ 9 a��al'S rr,.s�2�°"� �:b-i k� i� i• YYq t r4 i,_., 4 ₹3 ..i r k .Au i. N.�, £ +. xn,y�: �%; ,....A'3,,,,,44,.•.?'". ��#•a ms ° } ' ,:tt+1 fu.,.rN., �-:',•4t-0,,-,..., ,i a s J me r F S eA • f k1-i .aHf , i 3, .,. t-0,,`, *`ua r ' � - a ;.•' .g za, 4s a 4" t-`5o' .. 5, r a. M. � $12..35 7w ,,, County Basic ,^ Age 0-10...$17.01 $0.00 Maintenance -- Age 1 1-14...$18 8l $'66 No crisis intervention, Minimal14.1'`i•, Not needed or cover ilk CPA involvement.one lace-to- a a Rate Age 15-21 ..$20 09 ^ k,,,-,,i. under Medicaid. qA 6� M: face visit with child per month. ':".0,-! -. C' f $15.77 4, $5.14 '1` ��; Minimal crisis intervention as Regularly Scheduled $20.56 '' $.66 needed,one face-to-face visit ". N, $3.45 therapy up to 4 per month with child,2-3 hours/month. a ' " contacts per month ,ti .f. V, 1 Ys W " $23.99 $.66 $17.48 =?=: $19.20 $10.28 Weekly scheduled ,, {z-, Occasional crisis intervention as E_- awir 2 $27.42 �'•'. $.fib needed,two face-to-face visits therapy 5-8 hours a $4.97 a with child,2-3 contacts per *. month with 4 hours of .c' a° group month g P therapy. -- 2 Y2 $30.85 ; 5.66 �.• $20.91 74--,y,-- ' $22.62 , $15.42 fi Regularly scheduled k' Ongoing crisis intervention as weekly,multiple needed,weekly 3 $34.27 � $.66face-to-face sessions,can include "� $6.50 k. visits with child,and intensive more than I person. M coordination of multiple ''''. iTI: .e. family therapy,for ll' ,9-., services. f, 9-12 hours/monthly il, 3 1/2 .,.%'R', $37.69 $.66 $24.34 e - '.�`;' .5 fit,: e' 526.05 - ,,,,,,f- , Ongoing crisis intervention as Congregate needed,which includes high Care $41.13 . . 5.66 level of case management and Negotiated Negotiated Dro Down CPA involvement with child and P provider and 2-3 face-to face �,,1 contacts per week minimum. 44, ,.4•. . ,,„0,,,. ..„,,,,,,,,, ,, s_1„„,- r'S� s� 0, -�s t.,r° i r .r o- 7 ` rz i ' .,4- , ti O r ;;a_. S 'rr:7 D.,`l Is;','y _ r,...—Ss`_s d4 F '�A 4 Assessment/ yr1i,' Emergency $27.42 '�' $.66 $19.21) ' Level Rate R ,µ CWS-7A Individual Provider Contract 14 Revised 6/2015 IL z7 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this IS day of 0.44..2 20 l( by and between the Board of County Commission rs of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as,"County,"and Serna, Leo and Carol, whose address is 1020 Cottonwood Ave, Windsor,CO 80550, 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 he 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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 children) 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. ' 0,20/ -<_3c2.0. a C4) CWS-7A Individual Provider Contract (� 1 Revised 6/2015 JO � 7- 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(I IIPAA). 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 he 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: I. 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services,the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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 he 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 CW'S-?A 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. §8-17.5-102(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- (03(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 1., 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 Aug 17 15 03:27p Carol Serna 970-460-0181 p.1 WHEREFORE,the parties have herein set their ands and affiked their seals the day and date first written above. COUNTY: ATTEST:cis JC/040;t1 BOARD OF COUNTY COMMISSIONERS Weld u 'Clerk to th Board WELD COUNTY, C LORADO B_v: eput Cler to oard arbara Kirkmey , Chair CT g 7 2015 APPROVED AS O S it � .t r� +'�'•. , l.cted Offi .al or D r 861 �► ' e4� CONTRACTOR: Serna, Leo and Carol 1020 Cottonwood Ave Windsor, CO 80550 By: CAAA.,.&( Contractor's (or designee's)Signature and Date By: ��, �---t- �'lfj��" Contractor's (or designee's)Signature and Date 020/5'43a ( ) CWS-7A Individual Provider Contract 9 Revised 6120!5 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 Serna, Leo and Carol, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated 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# 1597453. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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 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. 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 (F1DOS). 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: I. 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 I 1 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. I1. 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: Select One Therapy;Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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? At How often is CPA/County case management required?(Does not include therapy) Select One **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. T1. How often are thera.v services needed to address child's individual needs per 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 g Self-injurious Behavior _ Select One ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ Emancipation Select One ❑ Eating Problems Select One ❑ Boundary Issues Select One Requires Night Care Select One Education Select One ❑ Involvement with Child's Family r 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) �r a a k.+�p-S `*4' fi y- ,! � ,` z,..€�m°.. F' * p:'$`'. -f ;` �S wy �r-b .. x'd,�` • ''13 K�3N,4'J,� �, i #'. ,14t ,A trF '1 .as s c ''')r '}:s �,, '1. R f % u x a,y Y . �t s}a r ' sta • ,7 i o j 4 W&O'' ' a -'' a ')..11.- -4 .Y 9 r r w .- rr : _ �i d 3+ gr!'1.0w Y ₹x '� a,� € ,4` ''y E ", $.m a i I f_ >� �1�'�E , �a �c i Fw ''�t t,� r-:t �.+ s zs 4 }�.� rw��`ro:,;.� ; ,, z ,,A a ,,,,:miocizi-eli . illiW ' - ., ' .4,'-1:,...zt.','WE - 4.",—r•'''sii' iV,1,...'"i:!'li4.:!:-fii'R...s.7-ii:,"-ii-: ',T1::";..f ' .::',i-Vitgl cda $12.35 County Basic Age 0-10...$17.01 .� $0.00 Maintenance Age 11-14...$18.81 $•66 No crisis intervention,Minimal x Not needed or cover 1 CPA involvement,one face-to- Rate Age 15-21...$20 09 face visit with child per month. ` under Medicaid. .,P.1 $15.77 t. $5.14 4 Minimal crisis intervention as Regularly Scheduled 1 411_; $20.56 $.66 t $3.45 x.. needed.one face-to-face visit 1.therapy up to 4 ' per month with child,2-3 *. hours/month. contacts per month s" 1 '/: kl $23.99 $.66 I $17.48 z1-.. $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 2 $27.42 $.66 needed,two face-to-thee visits therapy 5-8 hours a $4.97 with child,2-3 contacts per month with 4 hours of month group therapy. 2'/2 $30.85 $.66 I $20.91 tor + $22.62 $15.42 �, z ,.$ Regularly scheduled Ongoing crisis intervention as weekly.multiple „-... needed,week) face-to-face 3 $34.27 $.66 y sessions,can include $6.50 visits with child,and intensive more than I person, coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly'. 31/2 $37,69 $.66 $24.34 nx il v- $26.05 '.. 4 ¢,. t: Ongoing crisis intervention as Congregate s needed,which includes high sue, Care $41.13 $.66 Negotiated Negotiated level of case management and b g Dro Down CPA involvement with child and P . provider and 2-3 face-to face contacts per week minimum. s" ., x Ka `3 sue,,% #, t , r 't ' `'. '' z ` .',iw:<r "K` ,,,,T r�s v'' ''5 ?^�x t, ,.. .w ar�� .. '"r z : , ,i,-,, M Assessment/ • Emergency , $27.42 ; $.66 $19.20 a� Level Rate : CWS-7A Individual Provider Contract 14 Revised 6/2015 /D oa,21/ INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 7day of6-e,tf--/-4-&-?20 /6, 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 Sommerfeld, Angela and Robert, whose address is 6710 W 21st Street Lane, Greeley, CO 80634, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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. ab/�—tea 679 CWS-7A Individual Provider Contract I Revised 6/2015 /0 — ?- / '- 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. I-I. 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. §8-17.5-102(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: dirhA) .1C,u000k. BOARD OF COUNTY COMMISSIONERS Weld 'o my Clerk to the Board WELD COUNTY, COLORADO • By: Deputy Jerk o the : �I�"'�'*� Barbara Kirkmeyer, hair o T C U 7 2015 APPROVED AS TO S `� T C-r-( ®`� E e ted Offic':1 or De ' e �i 'DUO. CONTRACTOR: Sommerfeld, Angela and Robert 6710 W 21st Street Lane Greeley, CO 80634 By: , f Contractor's (or designe s) Signature and Date By: .-.) It Contra5tor's (or designee's) Signatur and Date c>2.Oi5,3O1aa (41) 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 Sommerfeld,Angela and Robert, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1654832. 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`1' of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. 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. 11. 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 /Z ' Z,21 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 1' day of6-e/C411--4- 20 Ai., 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 Stone, Mary and Jamie, whose address is 10112 W 13th Street, Greeley, CO 80634, 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: I. TERM: A. The term of this Agreement shall be from July 1,2015,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. cam: ,,,u/0-3a2 ( ) CWS-7A Individual Provider Contract 1 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. §8-17.5-102(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 (13) 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: ddrAdA) BOARD OF COUNTY COMMISSIONERS Weld C t lerk to the Bo rd WELD COUNTY, C LORADO By: Deputy erk to the Bo . Barbara Kirkmey r, Chair CT 0 7 2015 APPROVED AS TO SU% TA E tci'd Officia or Dep nt ISO -,os •.r �� '��►�'� ~\ : /TRACTOR: Stone, Mary and Jamie 10112 W 13th Street Greeley, O 80634 By: = ((46-- on r ctor s (or designee's) Signature and Date By: Contractor's (or designee's) Signature and Date c,20/. .3= 61.21) 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 Stone,Mary and Jamie, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1653349. 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 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. 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 1 1 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are therap services needed to address child's individual needs per 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 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) M1 LEVEL,OF' ,., m „fir „ RESPI"I'E SERVICE NIAINTF N\NCE MAIN[ENANCE SE:R\'ICES NEEDS s Rate Daily Rate F , 't. , Daily Rate County Basic Age 0-10...$17.01 $12.35 $0.00 y-flb No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover Rate Age 15-21...$20.09 CPA involvement,one face-to- under Medicaid, face visit with child per month. • $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled I $20.56 $.66 needed,one face-to-face visit R3.3- therapy up to 4 per month with child,2-3 hours/month. PP contacts per month '/2 s,;.)�) is $17.48 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 2 8" t_' $.66 needed,two face-to-face visits therapy 5-8 hours a S I') with child,2-3 contacts per month with 4 hours of month • group therapy. 2 '/2 4)-u.8-s $.66 $20.91 $22.62 $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 $34.27 $.66 needed,weekly face-to-face sessions,can include $6.50 visits with child,and intensive more than 1 person, coordination of multiple i.e.family therapy,for services. o 9-12 hours/monthly. 3 1/2 $37.69 $.66 $24.34 $26.05 4 Ongoing crisis intervention as needed,which includes high Congregate 541.B `,66 level of case management and Negotiated Negotiated Care Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. Alt Assessment/ Emergency $27.42 $(v, $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 �3O INDIVIDUAL PROVIDER CONTRACT • FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 7day of atilA--Gt), 20 /5, 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 Tauber, Nicole and Wright,Jon,whose address is 3919 W. 22nd Street, Greeley, CO 80634,hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETI I: 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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 children) 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: I. 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. aS ozo CWS-7A Individual Provider Contract 1 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 mxu, we wusrera++e..mttzm+.• 'ewuawaumar+ro»ax. a-orvnrxizv T .. ✓d, 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 612015 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 I 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 it; 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. §8-17.5-102(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- r 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. i 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, tires, 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 .. n'.i�A!'J/'+'[wtY1"ro..NufX.eWV.'t-sb 4wvx.R:.Mnp;hYtJ'4't'+Wt-0Y...rav •. WO.,•, • ar- • WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. diritel1) COUNTY:ATTEST: 'oi BOARD OF COUNTY COMMISSIONERS Weld n ' Clerk to t e Bo rd. WELD COUNTY, C LORADO By: Deputy t lerk to the Bo arbara Kirknley , Chair ocT o 7 2015 o;��, APPROVED AS TO UBS'T•v ` �,Lz� Elec e. Official •r Depart Si 4% ��1 . '•= ' 'RACTOR: Tauber,Nicole and Wright, Jon 3919 W. 22nd Street Greeley, 80634 By: C ntract is (or desi e s ig re a Dat By: ntractor's(or esi ee's) Signature and Date O2O/5-Ja (43) CWS-7A Individual Provider Contract 9 Revised 6/2015 f ` 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 Tauber,Nicole and Wright,Jon, hereinafter referred to as, "Contractor." GENERAL PROVISIONS I. 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# 1639129. 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 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. CWS-7A Individual Provider Contract 10 Revised 6/2015 AWOOM ate ‘ ; ;,. . 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. ?. 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. ('WS-7A Individual Provider Contract I I 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. 11. 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 .,AV..,AOWW • 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. PI. Flow often does the child require transportation by the foster care provider for the following: Select One Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. Itow often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera services needed to address _ :_.''" individual needs 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 • Substance Abuse Select One • Presence of Psychiatric Symptoms/Conditions Select One ■_ Enuresis/Encopresis Select One • 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 Select One complete the Medically fragile NBC) ❑ Emancipation Select One E Eating Problems Select One Boundary Issues Select One [ Requires Night Care Select One C Education Select One ❑ Involvement with Child's Family Select One Exhibit B to the Additional Provisions 13 Revised 6/2014 • I _. Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) LEVEL OF CH Z 11 RF i• MEDICAL SER\ICE M=tIN I LNANC L RI.SPI FE NIAIN`t F.N tN('I. I SERF I(ES NEEDS --- I oii k .�s.x,'. ,..'#{` .:aa a,,.e; s ..s* a :• e'en, llad K,�te ,,,,:. County Basic Age 0-10...S17.01 s $12.35 $0.00 ,,r, No crisis intervention,Minimal Maintenance Age 11-14...$18.81 0 CPA involvement one face-to- Not needed or cover Rate Age 15-21...$20.09 under Medicaid. face visit with child per month. $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled I $20.56 '.,;, needed,one face-to-face visit 53.45 therapy up to 4 per month with child,2-3 hours/month. contacts per month I ', $23.99 'l',I, $17.48 --------- ------ $19.20 $10.28 Occasional crisis intervention as - Weekly scheduled $27.42 c„ needed,two face-to-face visits ¢' therapy 5-8 hours a $4.97 with child,2-3 contacts per month with 4 hours of month group therapy. ' $30.85 $.66 $20.91 ,,- $22.62 $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 $34.27 t needed,weekly face-to-face sessions,can include Sty 501 visits with child,and intensive more than I person, coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. 3 1/2 $37.69 y r.,, $24.34 --------- T $26.05 4 Ongoing crisis intervention as Congregate needed,which includes high s i I "" level of case management and Negotiated Negotiated Care Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. 9 , { sM , Assessment/ Emergency $27.42 $19.20 Level Rate CWS-7A Individual Provider Contract I4 Revised 6/2015 „ �'r I INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made thisT� day of C./:?...P4-4--e-A-2, 20 /J , by and between the Board of County Commissioners of Weld County,on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County,"and Van Den Elzen,Dawn,whose address is 5819 W 16th St Ln, Greeley,CO 80634, hereinafter referred to as, -Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the 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 July 1,2015,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. 11. 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. c 2o7 <33aaa (`7I CWS-7A Individual Provider Contract I Revised 6/2015 /o 7, / �� 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. l8. To fully comply with the Minimum Rules and Regulations for Foster Family 1-comes 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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 he 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. §8-17.5-102(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 [-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 damailes. 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: dad tO‘4. BOARD OF COUNTY COMMISSIONERS Weld o n Clerk to the Bo d WELD COUNTY, CO ORADO . By: Deputy erk to the Bo arbara Kirkmeyer, hair OCT0 7 2015 APPROVED AS TO S STA► • E ed Offic" 1 or Dep me 4 a�i NTRACTOR: ,.:., ►S Van Den Elzen, Dawn 5819 W 16th St Ln Greeley, CO 80634 BY: 42iiarn el/17A.,1 7-3e)-,2e)/5 Contractor's (or design's) Signature and Date By: Contractor's (or designee's) Signature and Date (44) 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 Van Den Elzen, Dawn, hereinafter referred to as,"Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated 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#44282. These services will be for children who have been deemed eligible for social services under the statutes,rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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 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, CWS-7A Individual Provider Contract 10 Revised 6/2015 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 I9-3-304, C.R.S. 7. Maintain, access and review information weekly on FIDOS. CWS-7A Individual Provider Contract I 1 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. 11. 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; Select One Therapy;Medical Treatment;Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are therai services needed to address child's individual needs .er 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 Propert`Fire Setting Select One ❑ Stealing Select One Self-injurious Behavior Select One Substance Abuse Select One Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis./Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 Exhibit B to the Additional Provisions 13 Revised 6/2014 onoimommirmilimmeimor • Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) r r't y,.1,y r a r `nr f ; ; �k: r k ,r - t:'„;,::',,,:4-;-:5,.::;;;:i,,:, S q "� � �s`StC+`5�`•.�.w'a ��-�,`t� R�x�e��4 �' -v�£ � ,+ ,l' '"A, 91 .g$y r � vaD, r a 7til L, i a f' 9 'T + a � • �r .1 ��yy�,��s�s�. }v� n 2t a$ c �r ,8 °. s .btu a'�ixubrs� inks:. s. �'7 -,.,.„-gal.,,,„-,,,.Fy 4 '" '�w• t t,"iii..A'1"--:, 9 i� t' 4 i'tf,r RrCly� x,'a,, t A` F> 4-41.c,t t ;' ,�`r-, 1° S(x ,,'°„= r �C r 'r y,I` .`"F" _ N 6 ₹ y v.c--- ..-.:,,,,,-----.7--, $"`, ..,�„ ,41-.,.:,r. ,.•:.. -, - 5�'..: a j ,*Y!-,..--0 � 512.35 County Basic Age 0-10...$17.01 $0.00 $.66 No crisis intervention.Minimal ,,,i Maintenance Age 11-14...$18 81 Not needed or cover g CPA involvement,one face to ? , Rate Age 15-21...$20.09 under Medicaid. ' k face visit with child per month. , :'4',?1', st .- f y $15.77 55.14 ' Minimal crisis intervention as Regularly Scheduled ';',;-s 1 r $20.56 S.66 needed,one face-to-face v sit 53.45 # therapy up to 4t „.,• per month with child,2-3 hours/month. l contacts per month t '/: `- $23.99 . 5.66 • $17.48 .' ---- s $19.20 $10.28 -.7 Weekly scheduled Occasional crisis intervention as * ,�; i 2 sr: $27.42 5.66 Is», needed,two face-to-face visits 111therapy 5-8 hours a r_ $4.97 yr 'b with child,2-3 contacts per , month with 4 hours of ''"F J , } w month ' group therapy. If- 2'/: $30.85 � 5.66 $20.91 T $22.62 cl<- 515.42 I k Regularly scheduled ,fat''''' g y Ongoing crisis intervention as g g weekly,multiple .Y" 3 $34.27 } $.66 ,-` needed,weekly face-to-face sessions,can include $6.50 *w visits with child,and intensive .fz,,r #: more than I person. r ;; coordination of multiple i.e.family therapy,for services. , , , 9-12 hours/monthly. 3112 $37.69 = 5.66 $24.34 --------- ) --eti +' $26.05 .•41...''''i y >, = Ongoing crisis intervention as 4 needed,which includes high IL ₹ Congregate $41.13 $.6G level of case management and Negotiated IA, Negotiated Care . 4 Drop Down ; E , CPA involvement with child and liP, provider and 2-3 face-to face , .; a� contacts per week minimum. ,le/if ,`74'',". yT.� '' 4i ate+ ,i .1. Inca r } -' yt4 4f .5 man 4M, i '� t Trite 1, 't4f .k ry rp s'r ,.... �+!' s'. x .�ti � ..fir 8 -•�` '• �,,,,. . S- Assessment/ Emergency $27.42 ' g' $.66 � ., 519.20Waii Level Rate i4 "'" CWS-7A Individual Provider Contract 14 Revised 6/2015 C,ca,&,,c<A /P x`O23 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this day of , 20 b , by and between the Board of County Commissioners of Weld County: n 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 Wade, Michael and Jodyne,whose address is 1016 Cottonwood Dr, Windsor, CO 80550, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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: I. 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. t6: /AS//(114/ 01D/6- aa Cw'S-7A Individual Provider Contract I Revised 612015 /D 7- �� 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 612015 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. F. 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. §8-17.5-102(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. 0. 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 WI JEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: d•�@%uu/1/ �• i� BOARD OF COUNTY COMMISSIONERS Weld ,o nt Clerk to the Board WELD COUNTY, COI )RADO I3y: Deputy ler to the E3 arbara hirktneyer, .,hair oc 0 7 2C15 APPROVED AS TO SUBSTy. E R �` ue Fl t d Of'fici l or Dep. t O tt �(�' •� ,• g'` TRACTOR: Wade, Michael and Jodyne 1016 Cottonwood Dr Windsor, CO 80550 S C % acto (or designee's) Signature and i a e j- 67/S .�e Contractor's(+wr designee's) Signature and Date G2,p (4O CWS-7A Individual Provider Contract 9 Revised 612015 �2 � 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 Wade, Michael and Jodyne, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated 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# 1554152. These services will be for children who have been deemed eligible for social services under the statutes. rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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 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, 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 1 I 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 1. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? P4. }low 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) Select One **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. T1. How often are thera. services needed to address child's individual needs ter NBC assessment? Select One NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment Assessment Areas: Comment: Rating: ❑ Aggression/Cruelty to Animals Select One ❑ Verbal or Physical Threatenin Select One ❑ Destructive of Property/Fire Setting Select One ❑ Stealing Select One 0 Self-injurious Behavior Select One - ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ EnuresisiEncopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ Emancipation Select One ❑ Eating Problems Select One ❑ Boundary Issues Select One ❑ { Requires Night Care Select One ❑ Education Select One I ❑ Involvement with Child's Family Select One Exhibit B to the Additional Provisions 13 Revised 6/2014 S.. .. .. Q. Needs Based Care Rate Table ' Weld County Department of Human Service (Effective 7/01/2015) ' `�`k��: "� -„ I'. tit % z 1 ° s.. P; ,u , ,;.% xa,,�.;k3fs a F 1 rx . u3 ,sn z i .,§ "�1�` i�to�'� k a97y n �x.� s,? a '�4� � �� xc L v :' 4 '7 +�,t�" 7• .'rev t ,,, a -t- _ aw ,..t.". `t ,,V ------ b--'as m a=,p«ea,.€ 4r:,4_'� ,..,.a , .m., '., a''v.«.i }a't tr .s.,, . County Basic Age 0-10._$17.01 $12.35 $0.00 $,66 No crisis intervention,Minimal Iklaintenance Age I 1-14.$18.81 t: Not needed or cover CFA involvement.one face to Rate ' " Age 15-21..$20.09 �4 !> face visit with child per month under Medicaid. �w $15.77 $5.14 ,' Minimal crisis intervention as Regularly Scheduled $20.56 , $.66 needed,one face-to-face visit therapy up to 4 $34� pfol per month with child,2-3 hours/month. �, g . O, �s contacts per month rki1 %: $23.99 $.66 y; $17,48 $19.20 t: $10.28 K Occasional crisis intervention as Weekly scheduled fil 2 $27.42 $.66 �;' needed.two face-to-face visits ' ' therapy 5-8 hours a $4.97 '' month with 4 hours of with child.2-3 contacts per k k �' month group therapy. fq 2'2 $30.85 $.66 !t : $2t?.91 Ic $15.42 Ma I $22.62 rl 1 F'�" Regularly scheduled f! ' Ongoing crisis intervention as weekly.multiple needed,weekly face-to-face 3 $34.27 g; $.66 sessions,can include ,, $6-50 visits with child,and intensive more than 1 person, coordination of multiple .: _ i.e.family therapy_for 01 � � ' services. 9-12 hours/monthly. kit 3 Ill $37.69 "a vst $.66 $24.34 --: .04$26.05 iii 4 Ongoing crisis intervention as Congregate needed,which includes high Cafe $41.13 $.66 level of case management and Negotiated Negotiated Drop Down CP.A involvement with child and ' pros ider and 2-3 face-to face '' : contacts per week minimum. `.' t 7,;.,.`s..,','" .,.'�, ,-." -,*, �� .'; ... ',ua, 3� :t �.r,i,''',,> > i ,.<my r x �.'r <w„*'v''' Assessment/ :r; Emergency $27.4? $.66 $1920 ,,. Level Rate CVv'S-7A Individual Provider Contract 14 Revised 612015 35 INDIVIDUAL PROVIDER CONTRACT • FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this 7 day of hK•�a�.�-C.tJ 20 , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Walker, Kurt and Jennifer, whose address is 519 Trout Creek Ct, Windsor, CO 80550-3194, hereinafter referred to as, "Contractor." "[his 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: I. TERM: A. The term of this Agreement shall be from July 1, 2015,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. CWS-7A Individual Provider Contract 1 Revised 6/2015 /o -1-/� 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. I2. 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 6/2©15 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 • 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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 he 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. §8-17.5-102(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 1., 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, 1 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: detrAt4,1 G. idto;ti BOARD OF COUNTY COMMISSIONERS Weld un Clerk to the Board WE D COUNTY, COL DO By: Deputy lerk to the B Barbara Kirkmeyer, hair �+�,. OCT 0 7 205 APPROVED AS TO SUB v4 F La`� E c -d O�ici. or Iep $1 =t S ' �J•' �� ► NTRACTOR: Walker, Kurt and Jennifer 519 Trout Creek Ct Windsor,CO 80550-3194 By: 9-6) Contractor's (or designee's) Signature and Date By: C) _tip_ Cc Contra .or's (or designee's) Signature and Date o/ - 3a- (` 14' CWS-7A Individual Provider Contract 9 Revised 6/2015 J 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 Walker, Kurt and Jennifer, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1546248. 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 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. CWS-7A Individual Provider Contract 10 Revised 6/2015 C. Placement service reimbursement shall he paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall he 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 he an incidental beneficiary only. 7. No portion of this Agreement shall he 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: I. 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 he placed in the foster child's placement hinder. 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 612015 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. 11. 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. Pl. How often does the child require transportation by the foster care provider for the following: Select One Therapy: Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. Flow often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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. F-low 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) Select One **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. T1. How often are theca. services needed to address child's individual needs .er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 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) '?..r xx 3 a ,,.•a - * ' t ., x ,. s r '" � d .y�k � r � r� �grt��"C i Y'fi' �`�'-..' 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' ': 4 �, (" -7 ap'" '$`Y x Y 4,�Ippvpppk�� ki Y,„ ..,-..,-..vi,,,,,,.Y i �+ ,t^a,r ''''"' , `'ss '''. �£ u' F.,::',..'" 6+,3 8"r .t''a' , !� �.:f 744 n, '.� a�vil c ^Ii'llS� f., $ a;.'4,..'''"•'t Ri -nU Ci,;e�� 11 t `rs«' P Vir �3 r^ 4r , : ic..„ <ar4•t s�,,, ,tr ax J'' x", '"'i''`� 1, w .'.�.� .. 4r'.m`s . ,''.:I''/4 y�`r't4 ��'-' «v=r.-xi, r�<, 4,,₹4I'Vi.',.,�' �.: �� ti $12.35 County Basic Age 0-10...$17.01Y $0.00 $.66 ' No crisis intervention.Minimal Maintenance Age 11-14...$18.81 4,4'iNot needed or cover Rate Age 15-21 ..$20.09 CPA involvement,one face-to- under Medicaid. : face visit with child per month. 44 tirM $15.77 ", $5.14 Minimal crisis intervention as Regularly Scheduled 1 $20.56 $.66 L $3.45 needed,one face-to-face visit therapy up to 4 1 . '' per month with child,2-3 ` hoursimonth. contacts per monthKA H4 I ', $23.99 $.66 $17.48 'r" $19.20 $10.28 :*`1 Occasional crisis intervention as i4xl Weekly scheduled 2 - $27.42 $.66 •:,a,..„$ 5 8 hours a $4.97 needed.two face-to-face visits therapy "1.4 1, with child,2-3 contacts per . month with 4 hours of month group therapy. _ ; 2% 41'1 '‘A.-$30.85 -. $.66 $20.91 $22.62 $15.42 ' r Regularly scheduled • Ongoing crisis intervention as weekly,multiple 41 3 $34.27 $66. needed,weekly face-to-face l sessions,can include $6.50 visits with child,and intensive more than 1 person, � r coordination of multiple s i.e. family therapy,for aa, PY'• k, services. . 9-12 hours monthly. 7;a 31/2 $37.69 ,. $.66 $24.34 $26.05 4 Ongoing crisis intervention as , Congregate needed,which includes high $41.13 level of case management and$•66 Care Negotiated Negotiated Drop Down - CPA involvement with child and 1' :" provider and 2-3 face-to face "i5. contacts per week minimum. 1 p Assessment/ Emergency _ $27.42 ,, $.66 $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 ll� - 023 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this ;7 day of (AS+ , 20 Is by and between the Board of County Commissioners of Weld County, o h'behalf of the Weld County h' Department of Human Services,whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County,"and Willert, Melody D and Lee, Kimberly,whose address is 219 N 4th St, LaSalle,CO 80645, hereinafter referred to as,"Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS,the 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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. CWS-7A individual Provider Contract ; Revised 6/1015 O2.O /O-3,209-0161-1) /D- 7- /. 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 I I. 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. §8-17.5-102(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 �H�+�w1ta-s^�rm. ,:lx�uc-�... ti �LCt!�MM--` 1�dd' �:.�+Y r :�r..dhu u§;tCetbk�kf .•.,,.nom.°"",-�+r E�^mara+�S..r�cxim w�wa,u .: R:'-'-_- �S -'— WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: (/�GZ/N G� JO#41OARD OF COUNTY COMMISSIONERS Weld oµnt Clerk to the Boa d WELD COUNTY, COL RADO Deputy erk to the Bo r .aura Kirkmeyer, air 0CT 0 7 2015 APPROVED AS TO UB !re E c d Officia or Depart e F IlIktle � '�� • CTOR: Willert,Melody D and Lee,Kimberly 219 N 4th St LaSalle,CO 80645 By: 3cNCNILkoac)0_,L7') ontracto s(or designe-'s)Signature and .'.to By: V1?-7)IS- Contractor's(or ' s' nee's)Signature and Date CWS-7A Individual Provider Contract 9 Revised 6/2015 02.40 6P1 ar��tlN�IXP!.:lr ',p"A I.4A1'1"b"- ,..:�, ,, >t=; wubM >E ' gin."'>, WPM"-,'awns.-- `.A& ,14 O,,'ng€7' '" - -.� 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 Willert, Melody D and Lee, Kimberly, hereinafter referred to as, "Contractor." GENERAL PROVISIONS I. 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# 1540372. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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 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. 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. l 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera, services needed to address child's individual needs 'er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One complete the Medically fragile NBC) ❑ 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 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) LEVEL OF CHILD AD LINISTRATLVE ADMINISTRATIVE MEDIC al. RESPITE SERVICE MAINTENANCE MAINTENANCE SERVICES NEEDS Level Dai. ',.te Daily Rate Daily Rate aily ': Daily Rate rte County Basic Age 0-10...$17.01 1 $12.35 $0.00 s.60 ,r No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover Rate Age 15-21...$20.09 CPA involvement,one face-to- under Medicaid. p face visit with child per month. $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled I $20.56 '''66 needed,one face-to-face visit $'.45 therapy up to 4 per month with child,2-3 hours/month. contacts per month I V, $23.99 s.6r, $17.48 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled 2 $27.42 `x,66 needed,two face-to-face visits therapy 5-8 hours a $4.97 with child,2-3 contacts per month with 4 hours of month group therapy. 2 ''/ $30.85 $.66 $20.91 $22.62 $15.42 ' . Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 $34.27 s 66 needed,weekly face-to-face ; sessions,can include $6.50 visits with child,and intensive more than I person. 4. coordination of multiple i.e.family therapy,for ,; services. 9-12 hours/monthly. 3 1/2 $3-69 $.66 $24.34 $26.05 4 a Ongoing crisis intervention as Congregate needed,which includes high S4 113 $.66 level of case management and Negotiated Negotiated Care Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per week minimum. Assessment/ Emergence $27.42 $.66 $19.20 Level Rate CWS-7A Individual Provider Contract I4 Revised 6/2015 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this IS day of , 20 /.5 , 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 Wurtz, Drew and Workman-Wurtz, Katherine, whose address is 1901 15th Street, Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETII: 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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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 TIIE 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. /5-g02'9'2 /1/-e CWS-7A Individual Provider Contract / 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 [ndividual 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. I8. 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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 6/20I5 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: dj„ ) �. ..do%g1 BOARD OF COUNTY COMMISSIONERS Weld - u�y Clerk to the oard WELD COUNTY, CO RADO By: Deputy lerk to the t•�� 1+•arbara Kirkmeyer, hair p y� � /�� , y CT O72015 APPROVED AS TO SU; .T• ` '64i 861 E ct dOffici.. orDep• "'� CONTRACTOR: Wurtz, Drew and Workman-Wurtz,Katherine 1901 15th Street Greeley, CO 80634 By nt tor's(or signee's) Signature d ate B (ion ractor's (o sign s natu e and Date o/5- 30202-26/ CWS-7A individual Provider Contract 9 Revised 6/2015 1 ? .._— 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 Wurtz, Drew and Workman-Wurtz, Katherine, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1633330. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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 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. 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 I luman 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 I I 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. T1. How often are thera. services needed to address child's individual needs .er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ Runaway Select One ❑ I Sexual Offenses Select One ❑ Inappropriate Sexual Behavior Select One l ❑ Disruptive Behavior _ _ Select One ❑ Delinquent Behavior Select One ❑ Depressive-like Behavior Select One ❑ Medical Needs-(If condition is rated"severe",please Select One complete the Medically fragile NBC) ❑ Emancipation Select One j ❑ Eating Problems _ _ Select One ❑ Boundary Issues Select One ❑ Requires Night Care Select One ❑ Education Select One ❑ 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) r"- m 'w` .`°�"7" � 1•n°'i≥ Y s rn� ,ae fin. - $( a ` • X,'�`'ft.,' s 'F i': '', t'S+p 4'14. '.F t�'"i' ' f A � a x aw '' •-- a i E y x' , "„� .rvi l y a r ,w, %. 't,et a-t* 'a sny 71 y, x 1z� a :, t1,r 11�f �a' c,.5�` .a. �., „R + ,,y� '9 K .�"v0 �C" "� ., T 3 t 4 TM3 Pu i z.a G i1y '. . e-'�t_�q % r0' �# z r tea„ x 4,�t aat, �`a ,," ID '�;2'°4�Zv ti;�� "��g � � o = �3��" ;.'7Y*' �* .144-4.,,,,,,. .,� rdv F'i $ r'1�� '�` ...,,,,,„„,r,,,,..,,,� R z . * £ .: � ,t-1... ..., `aY ° i4i '�1 4 4 s, "'a, t , r ' ;'-'Fe i V'''" {+ a4 . ra,,, , 'If.s� -`, Cr ' .14 . rxS s, ' tid z 'a'5aFp YWI' .'0 . $12.35 County Basic Age 0-10...$I,.01 $.66 No crisis intervention,Minimal $0.00 Maintenance Age 11-14...$18.81 `- Not needed or cover CPA involvement,one face-to- Rate Age 15-21...$20.09 -� • under Medicaid. face visit with child per month. Ifff 5: n... $15.77 $5.14 Minimal crisis intervention as i 1 $20.56 $.b6 needed,one face-to-face visit I Regularly Scheduled ' $3.45 3, therapy up to 4 per month with child,2-3 _ hours/month. ` contacts per month tee 1 '/: ,i,'' $23.99 g, $.66 I $17.48 i$ $19.20 $10.28 ' 5 Occasional crisis intervention as Weekly scheduled 2 $27.42 $.66 needed,two face-to-face visits therapy 5-8 hours a $4.97 fit' t with child,2-3 contacts per :4-f month with 4 hours of ,. ,; month group therapy. 2 '/2 , $30.85 $.66 I $20.91 ' ' $15.42 s• $22.62 t 'o J! Regularly scheduled ; " Ongoing crisis intervention as weekly,multiple 3 $34.27 5,66 needed,weekly face-to-face ' sessions,can include $6.50 visits with child,and intensiveAlt .; ;'e more than I person coordination of multiple i.e.family therapy,for services. I'. 9-12 hours/monthly. 31/2 $37.69 Ai• $.66 1.4 $24.34 a' -. e $26.05 Ongoing crisis intervention as 4 Congregate needed.which includes high F $41.13 = $.66 ' level of case management and Negotiated Negotiated Care Dro Down CPA involvement with child and ,,SV p r provider and 2-3 face-to face contacts per week minimum. t F..-.tni� l„ . , tk,-.. ,,,-,4, .d' - ,:V .w . Aar' r - a, ,. #4,..4.- ., , . Assessment/ ia, �" Emergency $27.42 ,' $.66 $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 !D INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this --�J� -day of , 20•;,--",by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County." and Yost, Mike and Andrea,whose address is 1312 63rd Ave., Greeley, CO 80634, 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: I. TERM: A. The term of this Agreement shall be from July 31,2015,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: I. 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. �02 4q)mG / 020/ _/CWS-7A Individual Provider Contract 1 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form,which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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. NI. 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. dirAtki ,,,/ COUNTY: ATTEST: W JC. ►'tik BOARD OF COUNTY COMMISSIONERS Weld C• ty Clerk to the Bo•rd WE D COUNTY, CO ORADO By Deputy er .Y: arbara Kirkmeyer, hair 0 T o 7 2W5 t . 1161 t`�`•)'' APPROVED AS TO SUBST CE: A, Elect Official r Depart t Head Al/A Direct r of General Services • CONTRACTOR: Yost, Mike and Andrea 1312 63rd Ave. Greeley, CO 80634 / `/ By: " tee i • j�, ' Contractor's(or designee's) Signature a d Date By:CK),M6ISZ. . &S-V-71-3/ ':'.- Contractor's(or desgnee's) Signature and Date -' 07,076-502.244(Lq) CWS-7A Individual Provider Contract 9 Revised 6/2015 -17. 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 Yost, Mike and Andrea, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1658435. 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 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. 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 1 I 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. 11. 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 6/20 I5 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: Select One Therapy; Medical Treatment;Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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) Select One **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. TI. How often are thera. services 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One Enuresis/Encopresis Select One 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 Select One complete the Medically fragile NBC) ❑ Emancipation Select One El I Eating Problems Select One ❑ Boundary Issues Select One ❑ Requires Night Care Select One ❑ Education Select One ❑ Involvement with Child's Family Select One Exhibit B to the Additional Provisions 13 Revised 6/2014 mr Needs Based Care Rate Table .. • Weld County Department of Human Service (Effective 7/01/2015) - ' r ' -.,, §. . ""'. am` -° ` "7'" r " .,-.' [- ' .i+5°..; ,.a.»�.-e°,..i ua^4r; k ':L. ...:'''''P'' 4 k,4,4,02" .,rx.. i�a.,c.�,.a°.u.. _ ° ..._,.�. 3 a $12.35 fOf' , County Basic a Age 0-I0...$17.01 F. °^ $0.00 g <° $.66 14, No crisis intervention.Minimal `" Maintenance Age 11-14...$18.81 l Not needed or cover CPA involvement,one face-to- ,, Rate a!� ;1' Age 15-21...$20.09 face visit with child per month. under Medicaid. _,,ii:. �. w f $15.77 II'', $5.14 4 F Minimal crisis intervention as .�,.. c, Regularly Scheduled 4 I 520.56x. 5.66 needed,one face-to-face visit $3.45 therapy up to 4 t per month with child,2-3 hours/month. x -iro,; 4 5, contacts per month '. I '/z - $23.99 $.66 et'a $17.48 r lit 14 $19.20 $10.28 {�z1 e '° Occasional crisis intervention as +�"• Weekly scheduled 2 $27.42 $.66 �`' needed,two face-to-face visits therapy 5-8 hours a ,1 $4.97 '` month with 4 hours of with child,2-3 contacts per �zli, r i.�v; month group therapy. 2 / S30.85 $.66 sr $20.91 i it ) $22.62 $15.42 ti t.,,t *-. Regularly scheduledy Ongoing crisis intervention as ,; weekly, multiple 3 $34.27 = ° $.66 needed.weekly face-to-face sessions,can include $6.50 visits with child,and intensive K7 more than I person ' coordination of multiple ia i.e. family therapy, for x l'2". services. , 9-12 hours monthly 3 1/2 1 $37.69 $.66 $24.34 Y 4d 1 $26.05 4 Ongoing crisis intervention as Congregate ia: needed,which includes high Care .4i $41 13 $•66' - ; level of case management and Negotiated Negotiated _ CPA involvement with child and Drop Down ^' provider and 2-3 face-to face Y contacts per week minimum. -s3'. 1!lii �IK •"., .. +il'- r .. a t1 .. q f ,. .t., ,,,r .1 ft i s. �}p7x ads5. X00. '. _ _ ,,.. _A 1,-.--w HY' . , A" a ,�. �s'- r� T'� , k - .. . d ,,, 't. . . t Assessment/ ,. Emergency $27.42 1''` $.66 S19.20 f - Level Rate v 'iv ll CWS-7A Individual Provider Contract 14 Revised 6/2015 / D -foe INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this )--- day of , 20 l , 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 Arnett, Casey and Lindsay,whose address is 955 Crabapple Dr., Loveland, CO 80538,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: I. TERM: A. The term of this Agreement shall be from July 1,2015, 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. e e / /4(4/(. Revised 6/2015 CWS-7A individual Provider Contract4 /o 'j -/ ,P 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 L'dividual 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 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. 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. §8-17.5-102(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: dodo) jeitp;11 BOARD OF COUNTY COMMISSIONERS Weld o nt lerk to the Board W D COUNTY, COLO DO By: Deputy lerk to the Bo Rte rbara Kirkmeyer, C air OCT 7 2015 / �`� /♦j 1 APPROVED AS TO SU Elea Offici;l or Depar : •.y��, 1 _q CONTRACTOR: Arnett, Casey and Lindsay 955 Crabapple Dr. Loveland, CO 80538 By: 'C— ontractor' de ' ee's) Signature andyate / By: 7-..2 7 acto s (or designee's) Si nature and Date o2o/� j 2 Cam. 9 Revised 6/2015 CWS-7A Individual Provider Contract .._.__....... leTh 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 Arnett, Casey and Lindsay, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. 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# 1614609. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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 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. 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 I I 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. 11. 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: Select One Therapy; Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined in the treatment plan? P2. How often is the foster care provider required to participate in child's therapy or counseling Select One sessions? P3. How much time is the provider required to intervene at home and/or at school with the child in Select One conjunction with a regular or special education plan? 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 aae 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) Select One **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. T1. How often are them. services needed to address child's individual needs .er 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 ❑ Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ 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 Select One ❑ complete the Medically fragile NBC) ❑ Emancipation Select One ❑ Eating Problems Select One ❑ Boundary Issues Select One ❑ Requires Night Care Select One ❑ Education Select One ❑ I 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) 1J�..i=.Ytif OF-- -'-',, ,,,;...1'..‘- '-'..;::::-.1t44. F rr1.,Q,, �0,,,, 7 a'''yr 'L `. 1�R'�ICE' '''''''MA'''"'"''''..''''''''''''''`Ii";:"' ,,,,,,,,,i4„ 41�Il�'P�1�IAi'Q�� Eft �.� � r „#� x r• y k t , ^B S' apT,k ,?. d' J 4 w`F a S� g- ,eve1 D 'Y�t ° Dati Rate , , , Mill , ' f` � ~ Da y Rattih� `' ' . ,,,,i..,....,%;;;,,,,,, 'w'�7 ., x r -;�.w '�-"—ot ., 2.,,,,,A. x F , s,,. ,.n£ .....w5.- .� �' yam ..c-Sd �r .*., .,.fit... Rs __- fy �.. fa` qre. .. µ ' $12.35 $0.00 County Basic Age 0-10. .$17.01 $.66 No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover CPA involvement,one face-to- Rate Age 15-21...$20.09 under Medicaid. face visit with child per month. $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled 1 $20.56 $66 needed,one face-to-face visit $3.45 therapy up to 4 per month with child,2-3 hours/month. contacts per month '/2 $23.99 5.66 $17.48 $19.20 510.28 Occasional crisis intervention as Weekly scheduled 2 $27.42 $.66 needed,two face-to-face visits therapy 5-8 hours a S4.97 with child.2-3 contacts per month with 4e hours of month group therapy. $30.85 $.66'h %,s 2 $20.91 $22.62 $15.42 Regularly scheduled Ongoing crisis inters ention as weekly,multiple 3 S34.27 $.66 needed,weekly face-to-face sessions,can include $6.50 visits with child,and intensive more than I person, coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. 6,.>:, 3 1/2 $37.69 $.66 $24.34 S26.05 Ongoing crisis intervention as 4 Congregate needed,which includes high $41.13 $•66 level of case management and Negotiated Negotiated Care CPA involvement with child and Drop Down provider and 2-3 face-to face contacts per week minimum. . ,, ..* -• :.;'.'2-.. ' ��°' , ,.., *,4, _nay%.a., Assessment/ Emergency $27.42 $.66 $19.20 Level Rate CWS-7A Individual Provider Contract 14 Revised 6/2015 Hello