HomeMy WebLinkAbout20151007.tiff MEMORANDUM
1861
DATE: March 23, 2015
TO: Barbara Kirkmeyer, Chair, Board of County Com 'ssioners
-- �- N Ye FROM: Judy A. Griego, Director, Humari i s p• tln
RE: Individual Provider Contracts for P rpose of Foster Care
Services and Foster Care Facility between the Weld
County Department of Human Services and Various
Providers for Consent Agenda
Enclosed for Board approval is an Individual Provider Contract for Purpose of Foster
Care Services and Foster Care Facility Agreement between the Department and Various
Providers. These were reviewed under the Board's Pass-Around Memorandum dated
May 22, 2014, and approved for placement on the Board's Agenda.
The major provisions for these Agreements are as follows:
No. Provider/Term Facility Type/Location Daily Rate
• 1 Calvillo,Vanessa and Kaebler,Ryan Foster Home $16.73 - $40.44
July 1, 2014— June 30, 2015 Loveland, Colorado
2 Dreweck, Jeremy and Haley Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Loveland, Colorado
3 Erbacher, Dand and Hattie Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Greeley, Colorado
• 4 Fitzpatrick, Thomas and Cheryl Foster Home $16.73 - $40.44
July 1, 2014 — June 30, 2015 Fort Collins, Colorado
5 Froggatte, Samuel and Rachelle Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Greeley, Colorado
- 6 Grizzle, Phillip and Nicole Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Greeley, Colorado
- 7 Hartness, Riachard and Marlaena Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Platteville, Colorado
8 Heard, John and Kimberly Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Mead, Colorado
9 Heimer, Sara Foster Home $16.73 - $40.44
July 1, 2014 — June 30, 2015 Greeley, Colorado
10 Hernandez, Roberto and Margarita Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Fort Lupton, Colorado
' 11 Hoeft, Kimberly Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Eaton, Colorado
(�Wi4AX1' - 12 Kirchoefer, John and Erin Foster Home $16.73 - $40.11
July 1. 2014—June 30, 2015 Fort Collins, Colorado
Ai-/ a /5 Cc an- /40 x,t,.s e-4-> *00849
13 Land, Brad and Molly Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Greeley, Colorado
14 Roderick, Douglas and Kelli Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Greeley, Colorado
15 Tauber, Nicole and Wright, John Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Greeley, Colorado
16 Walker, Kurt and Jennifer Foster Home $16.73 - $40.44
July 1, 2014 —June 30, 2015 Windsor, Colorado
If you have questions, please give me a call at extension 6510.
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT �p
THIS AGREEMENT is made and entered into this/3 day of Meg-- , 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 Calvillo, Vanessa and Jaebker, Ryan, whose address
is 4179 Plum Creek, 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"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, 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.
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.
02O/j--/DD 70)
CWS-7A Individual Provider Contract I Revised 6/2014
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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 6/2014
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 ndes 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, S150,000 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 6/2014
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.
C\S-7A Individual Provider Contract 4 Revised 6/2014
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 6/2014
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 6/2014
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 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
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 6/2014
WI IEREFORE, the parties have herein set their hands and affixed their seals the day and
elate first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: djr, ga, W ,64. of I luman Services
By: ---1-1:7,`-.-
Deputy By�� C �eti
lerk to the •'��' (( Barbara Kirkmeyer, Chair
ice-,< •Q �. APR 1 3 2C15
t`" TRACTOR:
Approval as to Substane c 2\9 rs'
WELD COUNTY DEP g�t ilillo, Vanessa and Jaehker, Ryan
OF HUMAN SERVICE . e k,.t/44 �A Plum Creek
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By: / Fi� � By: C 2 0 ` ` `
only Di ector's r desi nee's) Contractor's(or designee's) Signature
i nature nd Date and Date
By:
Contractor's(or designee's) Signature
and Date
020(5- /0 0 7 6 )
CVs-7A Individual Provider Contract 8 Revised 6/2014
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
APPROVED AS TO FUN iliNG:
?0 Aal.4 ( 22/12&
Controller
AP'Tt J • FO: .
Cou ,. •ttorney
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 Calvillo, Vanessa and Jaebker, Ryan, 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# 1652850. 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 6/2014
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 6/2014
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 I I Revised 6/2014
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 VIT and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
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. I low°lien 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 roster 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. I 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. 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 he assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
Ti. I low 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/ire 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
❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
R 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)
LEVEL OF CHILD ADMINISTRATIVE ADMINISTRATIVE MEDICAL
RESPITE
SERVICE MAINTENANCE MAINTENANCE SERVICES .., NEEDS
Level Daily Rate Daily Rate Daily Rate Daily Rate Daily Rate
S 12.I4 S0.U0
Count} Basic Age(1-10...S16.73 S.66 No crisis intervention,Minimal
Maintenance Age 11-14...SIK.50 Not needed or cover
CPA involvement.one face-to under Medicaid.
Rate Age 15-21...S19.75 lace visit with child per month.
S15.51 $5.05
Minimal crisis intervention as Regularly Scheduled
1 520.22 5.66 needed,one face-to-face visit S3.39
therapy up to 4
per month with child.2-3 hours/Month.
contacts per month
1 '// S23.59 $.66 S17.19
S18.88 510.11
Occasional crisis intervention as Weekly scheduled
2 S26.96 S.66 needed,two face-to-face visits therapy 5-8 hours a S4 89
with child.2-3 contacts per month with 4 hours of
month group therapy.
2 '/: 530.33 S.66 520.56
S22.24 S 15.I6
Regularly scheduled
Ongoing crisis intervention as weekly,multiple
3 $33.711 S.66 needed,weekly face-to-face sessions,can include S6.39
visits with child,and intensive more than 1 person,
coordination of multiple • i.e.family therapy,for
services. 9-12 hour.simonthly.
3 1/2 S37.06 5.66 S23.93
— — S25.61
Ongoing crisis intervention as
4 needed,which includes high
RC'C:F S40.44 S.66 level of case management and Negotiated
Drop Down CPA involvement with child and
provider and 2-3 face-to face
contacts per week minimum.
Assessment/
Gmergenc S26.96 S.66 S18.88
Level Rate
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this (pef'day of Oc *tr ,20\4 ,
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 Dreweck,Jeremy and Haley,whose address is 2759
Empire Ave,Loveland,CO 80534,hereinafter referred to as,"Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS,the Colorado State Department of Human Services(hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home(hereinafter referred to as"Facility"), and
WHEREAS, Contractor understands and agrees that it must,during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards,and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department,and
WHEREAS,County may, but shall not be obligated to,purchase foster care services,and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW,THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014,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 6/2014
�oO 7(
-f-Rco'SC-P
.A. �a
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 I luman
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 t ster 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 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.
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.
('N'S-7;1 Individual Provider Contract �' Revised 6!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(HIP AA).
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 I luman Services, the Colorado Department of I lealth 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.
('WS-7A Individual Provider Contract 3 Revised 6:'_'014
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,
NN,ith the provider before placement and to share additional information when
obtained.
2. '1'o 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(lithe 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 ofan
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 l luman
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.
CwS-7A Individual Provider Contract 4 Revised 6!.10 1 4
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 fix providing information on county specific
procedures.
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.
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 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 he 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 o1'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 6,2014
the purchase of services in this Agreement arc 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 Slate Department may provide consultation to Contractor to
assure satisfactory perlbrmancc 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 alter final payment hereunder.
Ci. Time is of the essence in each and all of the provisions of this Agreement.
Fi. 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. 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 staled 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. 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 he 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
ofor 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. Arc 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 (Li)above.
4. Have not within a three-year period preceding this Agreement, had one or more
C'WS-7A individual Provider Contract 6 Revised 6.'201 4
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 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:
1. Withhold payment to Contractor until the necessary services or corrections in
performance arc 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 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.
P. No portion of this Agreement shall he 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'WS-7A Individual Provider Contract 7 Revised 6'2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
� � County, on behalf of the Weld County Department
AT TES of Human Services
r
By: By- 1A-P-41..4.4--
I)eputy erk to the Boa - Barbara Kirkmeyer, Cha:ir APR 1 3 2015
r
4 )NTRACTOR•
Approval as to Substan4 ,, '
WELD COUNTY DEP1,040:11412
veck,Jeremy and 1laley
OF HUMAN SERVICE ' `� , Empire Ave
k- , eland.CO 80534
C t my Dir c or's o designe 's) Contractor'"s(or designee's)Signature
. ig azure a d Date and Date
. • - , •-' I /
.;
Contractor's(or designee's)Signature
and Date
c›20/5/00 7 67)
('WS-7A Individual Provider Contract 8 Revised 6•'2014
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
APPROVED AS TO F ND�G:
SO C7)42&
Controller
APP D
Coun rney
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 ibr Purpose of Foster Care Services and Foster Care Facility Agreement." hereinafter
referred to as. "County,-and Dreweck,Jeremy and Haley. hereinafter referred to as.
"Contractor."
GENERAL PROVISIONS
I. County and Contractor agree that a child specific Needs Based Care Assessment.
designated within this exhibit as Exhibit B, shall he 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
tipster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-
adoptive placements will he 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 he 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 I Iome
identified as Provider ID# 1639704. 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 pertbrmed. Any
payment for specialized services not authorized in writing mar he 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'WS-7A Individual Provider Contract 4 Revised 6/2014
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. It-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 (l IDOS).
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 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.
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 he 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 he 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 I luman 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.
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 62014
administrative agency,shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benetit 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 HDOS.
8. Read. he 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 hinder will he reviewed on
a monthly basis and signed oft'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.
13. 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
C'wS-7A Individual Provider Contract I I Re%ised 0.2014
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 liar 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.
C'WS-7A Individual Provider Contract 12 Revised 6;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.
PI. I low often does the child require transportation by the foster care provider for the following: f 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. l fo‘‘ 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. 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. I low often is CPA/County case management required'?1 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 Properly:Fire Setting Select One
Q Stealing _ Select One
^❑ Self-injurious Behavior Select One
t—❑ t Substance Abuse Select One
O Presence of Psychiatric Symptoms/'Conditions Select One _
❑ 1.nuresis/Encop esis _ _._.-...-_--. Select One
❑ Runaway Select One
❑ Sexual Offenses _ Select One
❑ Inappropriate Sexual Behavior Select One
❑_ Disruptive Behavior Select One
Delinquent Behavior Select One
D Depressive-like Behavior Select One
❑ Medical Needs-(If condition is rated"severe",please Select One
complete the Medically fragile NBC)
— 1.mancipation --� Select One —_
--- —❑_ Select One Eating Problems❑� Boundary Is Select One
sues
❑ Requires Night Care t Select One
❑ Education Select One
❑ Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 612014
EXHIBIT['
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
+fY: vd� E. � ..,t �. y. ry l-Sg .. Re- .
'" ,r a �.' II t �sav _'tY�, - ".t r,rla"^ �" , :` ,7` ,,, .
n+4' � k rir4MT *r R +fi t��it�l i I" } , �ltiie�tu"-
{ 44, a ' M � g , y` . l�E 7 ANyy�,�T.
ley D`a"' � ,� }'4 ..5 1_; '',.� ��t ' •'1 a'a #1r t,G f.2a.'
rl�i .7 • Y ♦ /' 'lY Y Y'44Llev ^. ''� :, , Dail Rate x `f* �T ' t t +a
l'uuntp Basic Age 0-10...S16.73 `s �:0: SI?.I l � $0.00
P? $.li6 \o crisis intencntion.Minimal `- '-
'Maintenance le; Age II-l•l...S18.5(1 Not needed or cover
( l• in.olsentcnt.one itce-to- l 1`
Rate ;rf Age 15-21...519.75 '.l under Medicaid. '9'�
�' tau%Nil�%.ith child per month.
rya,• t
/ t
` . ' • $15.51 '4i `,
'?'t r ti a�' S5.u5
y*� r..
Y. Minimal crisis inten•emion as rh as
1 5311.2? x' $.66 Regularly Scheduled
w• needed,one lace-to-lace visit ;'�• as,; 53.39
;�k! therapy up to a
per month with child.2-3 'd:�r
,a hours month. •
contacts per month ,:4
I '/r $23.59 Tit` $.:‘.:::'1
66 S 17.19 •:tiQ ,r
-- _ 17 SI8.88 r'', _ S10.II
4. ✓: �T
lax. j? t 11 cekly scheduled
s Occasional crisis intcnrmion as
2 $26.96 }"v' S.66 tt1 needed.too lace-to-face.kits therapy 5-8 hours a $d.a:9
`:• oith child.?-1 contacts per �, month s[ith 4 hours of
- ' . month r',y'..., group therapy.
i ,....,
2 !i 111. $30.33 Zir $.66 $20.56
tkir
$22.24 $15.16
`1 ='' Regularly scheduled ''c"
*•'-2 Ongoing crisis intcncntion as "= sleekly.multiple w:^
needed,oeckly face-to-face p f
} �, $33 70 .T $.66 i. sessions_can include f--., 56.39
visits with chill.and intensive person.
- nurcc Than I
?, coordination of multiple i.e.family therapy.litr
seniva. },K, 9-12 hours'monthh. ,.
31, 537.06 " .
'2 S.66 S2?.')? � '`
v.
y $25.61 2;1i=
R i ,'.,
164 Ongoin crisis in .m as ; w
t neededg.tthich includes high
ltl ( I S40.-1.1 $.66 �r: Negotiated
level of ease management and .y
Drop DuoII �( ] ('P:1 intolvelttent oilh child and i,
provider and 2-3 face-to lace a'
"': contacts per oem k minimum.
n•'"�F➢!'. : 7.t f 1.i'.s.E�4'.1i F. ;4400V?f H.* . i 3'. _ 4'J' _ Ufi;'t i:' y4'.r'n_r ' l�c
.%s%es.ment/ 'Z - .
Emergency , $'-6.96 66 �`.' 518.88 'e
I.cscl kale , ;
Exhibit C to the Additional Provisions I4 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this /5 r day uI uL-• 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 Erbacher, Dan and Hallie,whose address is 3850
Cheyenne Dr,Greeley,CO 80634, hereinafter referred to as."Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSi:I•II:
WHEREAS, the Colorado State Department of I luman Services(hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter I tome(hereinafter referred to as"Facility").and
WI iEREAS.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 he fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department,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 Facility's certificate/license and without prior notice.
NOW,TI IEiREFORE, 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 1,2014, 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 children) may he placed elsewhere.
whichever occurs first. and the liability of the parties hereunder for further
performance ol•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. AGREEMENT'S OF *I1 IF PAR'T'IES:
A. Contractor agrees:
1. To tiu•nish 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.
S-7A Individual Prodder Contract
Revised(v2014 O1,5--/OO 7(5)
(O&0
2. 'fo 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 tester 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 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 oldie child.
c. An serious injury to the child.
d. An.. 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.
u. Any emergency.
It. Any pertinent discussion with parents or guardians about the child or
supervising agency.
C'%S.7,\ Individual Provider Contract '_ Revised 6'_QI4
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).
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 billy 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 arc 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 luman 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
he 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 tor
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 6/201-1
27. 'l'u 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 he
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.
(i. To involve the provider in service planning li')r the child as part of the overall
treatment team.
7. 'l'o 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 fi)llowing placement.
S. 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 fir placement elsewhere. or without such waiver in the event ofan
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.
("WS-7A Individual Provider Contract
Ke‘iseJ G`_Uld
10. 10 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.
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 fonts. 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 he.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 he 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.
i). 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 he in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
L. 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
('W 5.7A individual Provider Contract
5 Revised 612014
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.
[ . County shall have access to Contractor's financial records as they relate to this
Agreement tier purposes of audit. Such records shall he complete and available for
audit 90 days alter 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 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. tires. strikes. war. flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be 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 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.. 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 he 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. I lave not. vv ithin 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
Revised 6/2014
C'WS-7A Individual Provider Contract t'
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. kxhihit 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 tbllowing:
. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
Z. Deny payment or recover reimbursement fur those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed 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, 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 otherw ise 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 he 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.
0. 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. l'he
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 documents)to the County
Director. The term "litigation" includes an assignment for the benefit of creditors.
and filings in bankruptcy, reorganizations and/or foreclosure,
Revised 6:'_1113
('WS-7A Individual Provider Contract 7
WI II:RI:;FORL.the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
'The Board or County Commissioners of Weld
County.on behalf of the Weld County Department
ATTEST: didi+ W. of l luman Services
By- /` -
Deputy rk to th i$
` r Barbara Kirkmeryer, Chait APR 1 3 2015
.
NTl2ACTOR'
Approval as to Substa t i `."' '= Avg
WELD COUN fY I)l lK , ? ; aeher. Dan and I lallie
O1' HUMAN SIRVIC ' kiis k 5(S Cheyenne Dr
'' '^-,. Ate, ` ireeley.CO 80634
, -14.4:17...,'BY: ,j , . 1,. U:01-) By: .5-)�., 7 I Iy
Co n v Dir•ctc is(or s 'nee's) Contractor's(or designee's) Signature
Si ,na ore and ate and Date
54 ///(71
Contractor's(or designee's)Signature
and Date
(A\'S-7A Individual Provider Contract 8
,2Q/,—, /OO 7(-5)
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
APPROVED AS TO F ND
Controller —_
Cou ,- ' torney
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 Erbacher, I)an and Ilallie. hereinafter referred to as.
"Contractor.-
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Biased Care Assessment,
designated within this exhibit as Exhibit B, shall he 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 he 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.
�. 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 he 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# 1546381. These services will be for children who have been
deemed eligible for social services tinder 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 hetore payment will
he 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
writinh by the Department Administrator. prior to the service being performed. Any
pa}meat 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. lithe
reimbursement request is not submitted within twenty-five(25)calendar days of
the month following service, it may result in forfeiture of payment.
9 Revised 6/2014
CWS-7:\ Individual Provider C•untra�t
.
C. Placement service reimbursement shall be paid from the date of placement up to.
but not including the day of discharge.
1). Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed.Contractor will arrange reimbursement through
Medicaid. Any other special requests fiw transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
I'.. 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 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 l luman Ser ices 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 he defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed:
[;. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would he of no value to the
Human Services. Denial of the amount (A-payment shall be reasonably related to
the amount of work or deliverables lost to I{man 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 I luman Services and the Contractor.or by I luman
Services as a debt to Human Services or otherwise as provided by law.
p. Contractor shall promptly notify I Inman Services in the event in which it is a party
defendant or respondent in a case. which involves services provided tender the agreement.
The Contractor, within live(5)calendar days after being served with a summons,
complaint, or other pleading which has been tiled in any federal or state court or
(VS-7:\ Individual Provider Contract
10 Revised 6:20 14
administrative agency. shall deliver copies of such documents)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.
?, Request a stalling 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 Weld County Department of I luman 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 luster 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.
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 case"orker and/or the Contractor's Foster Care
Coordinator.
I0. Maintain/update medication logs on a daily basis. ifchild is taking medications.
1 1. Maintain behavior observation notes as required by the level ofcare 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
('WS-7A Individual Provider Contract
I l Revised ó'2014
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. lalsitication or destruction ofrecords. 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 (13)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 tiwth in the State
Department rules. Staff Manual Volume Vii and the Weld County Department of human
Services Policy and Procedure manual.
(''. S-7.\ Individual Provider Contract 12
Revised<i'?1114
rAIIl8lT 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. I low often does the child require transportation by the taster care provider for the following: } Select One
"therapy:Medical Treatment:Family Visitation;Extraordinary Educational Needs;etc..as outlined II
_ in the treatment plan? — —— r Select One
P2. I low often is the foster care provider required to participate in child's therapy or counseling
sessions?
P3. How much time is the provider required to intervene at home andfor at school with the child in Select One
conjunction with a regular or special education tan?
P4. I low often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities andkor crisis ntana emoat?
P5. I line much time is the provider required to assist the child because of impairments beyond ase Select One
appropriate needs with feeding,bathing,grooming.physical.and:or occupational therapy'?
Al. I low 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.
11. How often are thcra.v services needed to address child's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
— " Comment: Rating:_
Assessment Areas: Select One
A„Lrc,sion Cruelty to Animals '----^—n- — —
❑ ' —""-- Select One
❑ ---r`verbal or Physical Threatening,
❑ Select One
Destructive of Property-Fire Setting Select One
❑ Stealing - - - Select One —
❑ Substance Abuse Select One
l� Presence of Psychiatric Symptoms'Conditions Select One
❑ ---
_ Fnuresis'Encupresis
------ f Select One
El Runaway Select One
❑ ' Sexual Offenses , Select One
IT—Inappropriate Sexual Behavior Select One
❑ Disrt�tive Behavior _ ---—- — Select One
El Delit�i uent Behavior - -Select One
❑ Depressive-like Behavior Select One
7.❑ Medical Needs-(If condition is rated-severe".please —�— — � --- - - — -
complete the Medically fragile NBC) _-,_ S@lect One
—
I::nuuteipatlan - __. --— -
—---- Select One
d Eating Problems blcros - Select One
ID liuundar; Issues Select One
Q Requires Night Care Select One
� ❑ Education One
r - Involvement with Child's Family
Exhibit B to the Additional Provisions I
Revised 6/2014
' F:XII IIIIT C'
Weld Count} I)epartnlent of Ilun►an Service
Needs Based('are
Rale'Table
(Effective 7/0I/20I4)
mss ;
LEVEL OF ' CHILD ADMINISTRA'nVE • ADMINISTRATIVE MEDICAL
SERVICE AINTENANCE RESPIRE
MAINTENANCEMAINTENANCE SERVICES DEEDS
Level • Daily Rate - Daily Rate - Daily Rate . Daily Rate Daily Rate
512.1.1
('ouni Basic Age 0-I0...$16.73 50.00
$o', No crisis infe"c"tion.Nlininull
Maintenance Age I I-14...S11i.50 Not needed or cover
t C'I',1 involvement.one face-to- under�IrdicaiJ.
Role ;*: Age 15-21...S19.75 lace visit ttith child per month.
- - .. — — --•-,--.... .-._ —
S 15.51 S5.0
4lininlal crisis intervention as • kCgularlt Scheduled
- . $211.22 5.66 IICCtlitl-one lace-lo-Iil\l't hll S3.39
._ therapy up to 1
• per month with child.2-. hour,nnlnth.
contacts per month
.-- .. ,:;..- —
'/I 523.59 SH, $17.19
—r-r
S l l;.:t;t S10.11
Occasional crisis intervention as 11'eekly scheduled
•
S26.06 5.66 needed.Itttl face-O-race visits therapt 5-8 hour a $4.89
tsith child.2.3 contacts per . month«its 4 hours of
month group therapy.
2'1; S3(i.33 S.66 $211,56
— --- ":
$22.24 S1.5.16
- Regulars scheduled
• : t)"going crisis intervention as weeks).multiple
J (1$33.' . . s rs, "ceded.tteekIs face-to-Iace sessions,can include - 56.39
.. visits v%kb child,and intensive more than I person. •-
coordination of multiple : ' • • ,I.C.lamily Inc:ropy.for
scrs ices. : 9-12 hours•`monlhly.
t1 - N $.66 523.93 -
$25.61
t I"rt,I l l 1.I.I I i s iii ICI t Clltlt 111 in'.
4 "ceded."hid)includes high
R((F S-10.14 S r,r, level of ease management and Negotiated
Drop Dunn ('PA insohcment with child and
pros ider and 2-3 lace-“,race
contacts per steel.minimum. •
.\sscssment/
Emergency s''!' s nn $I}t.1i
Lesel Rate
Exhibit C to the Additional Provisions 14 Revised 6'2014
w
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this / day of Tide/ , 20_ I 1/41,
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 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 he from July 1,2014, 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.
/007(4-
CWS-7A Individual Provider Contract I Revised 6/20,1144 p
ft 12,00%
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 6/2014
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 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 he amended from time to time, and shall
he 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 6/2014
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 6/2014
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.
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 shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are can-led 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 6/2014
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 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 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
(� Gl r a.J_� /, County, on behalf of the Weld County Department
ATTEST: �j (i of Human Services
By By
Deputy C rk to the Board arbara Kirkneyer, Chair '^R 13 2015
CONTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT Fitzpatrick, Thomas and Cheryl
OF HUMAN SERVICES 324 Saturn Dr.
Fort Collins, CO 80525
1, V
1'
By i, By: c (A t—
,o my Di ector's ('r design 's) Contractor's(or des' nee's) Signature
Si nature • nd Date and D'
By:
Contractor's(or designee's) Signature
and Date
a %5-/o07 (-4)
CWS-7A Individual Provider Contract 8 Revised 6/2014
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
APPROVED AS T FU
-roller rl1.a
Controller
AP OR
f • ORu•
Coun torney
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 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# 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`h of each month following the month of service. If the
reimbursement request is not submitted within twenty-live(25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
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 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. [he 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 he 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 heing served with a summons,
complaint,or other pleading which has been filed in any federal or state court or
CWS-7A Individual Provider Contract I Revised 6,2014
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.
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. 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 6/2014
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. 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.
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.
C\VS-7A Individual Provider Contract 12 Revised 6/2014
i:X1iIBII' i3
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 edycati2nn 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. b 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 ire sibling
group
or more than one County foster child is with the same provider.
71. How often are ther • 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:
Ti 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
] I Substance Abuse Select One ,
Presence of Psychiatric Symptoms/Conditions Select One
• Enuresis/Encopresis Select One i
❑ Runaway Select One
❑ I 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)
O Emancipation Select One
❑ Eating Problems Select One
Q , Boundary Issues I Select One
❑ Requires Night Care . Select One
❑ Education I Select One
• ❑ Involvement with Child's Family T Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
r .
EXHIBIT C:
Weld County Department of Unman Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
„'e'er .. . .`•. --- r• •=,..O„,1;;- G ° ,-.y .r. -f,,rt 4 f; ,, ,1 - "''f ..
k �}: t� 6t +.�.+' &+ a i...1 t-t�t:a zal y,rs�, i + �,,,. ..
r r.
` -;-•_ •t''''''. .L�:-..'l a SI n;' t ,..,,,e,;,-.,,4..,,i7-
i� ?ate X•,�`�•�•'i'F 1/�•' �. r•-f-,...-.,•..,:e
•- ,,e - -
. 4. - A!;: ?. ''+ `r d1t,T�E'f').`i R -:3 '� i'k t�Sfx 'i,*a-:r t .;1-... .-4-.V.-. ..'. ':i
,� i.V i ,.j •• / '',;. C . Y - ..- - v�,�
n ?c'.'�� ti � � c��'t^i ; � far m 4..r.,.?� +" `,',1*::.;,y�l�' Jr �� " �q�M'�3”
' ,fi11 °° `�. ',et. ..g¢as. i - _ ..1.:* •'y"' 1K....'r»..,-- .}�'F .a ri Ads t•. ....err C_Ys. "r'�i:a• gist. ..5' '::
County Basic Age 0-10..,$16.73 $12.14 $t1.00
,ca:- -7,- 5.66 No crisis intervention,Minimal
Maintenance -'.w` Age I 1-14...$18.50 Not needed or cover k
CPA involvement.one face-to- ''F
Rate Age 15-21...519.75 under Medicaid. '
3�' s3. face visit with child per month. ,-,It --;'; :'-
'*`"' ' t
£ $15.51 $5.05 ;
- Minimal crisis intervention as Regularly Scheduled I
needed,one face-to-face visit up
' _ therapy to 4
, S3 39
per month with child,2-3 hours/month. it'
A .. „.. contacts per month
I v $23.59 5.66 $17.19 ;
yam. $18.88 - $10.11 ,�
ta' Occasional crisis intervention ati �L Weekly scheduled
2 $26.96 f.. $6t> needed.two face-to-face visits therapy 5-8 hours a $1-89
with child,2-3 txmtacts per IC; month with 4 hours of
ate' month it group therapy.
2 26.1 5'0 1; ` 5.66 $20.56 _fr„.7
yNr $15.16
r ---.E.
$22.24 ' ,
Regularly scheduled `;,s,
!t' 1.
Ongoing crisis intervention as weekly,multiple 4e.;
Ck2
i,- $33.70 :' needed,weekly face-to-face �;
3 r..' _ 5,66 sessions,can include .1' 56.39
_ ±, visits with child,and intensive
', more than I person_
coordination of multiple
k•; i.e.family therapy,for
ser ices. 9-12 hours/monthly.
4 I : [ -.
3 1/2 0..;, $37.06 S. $23.93 ,_
,„
$25.61 iftfut 1,40
•e''.-`., Ongoing crisis intervention ac
4 s g L. needed,which includes high
'dr'. $40.44 "g- 5.66 level of case management and :^.,^s — Ncgolarcd
Drop Down t‘zs ;. CPA involvement with child and l"'+:
provider and 2-3 face-to face re
,. contacts per week minimum. .:
tt gg�,�yyewe��
1. .4 f"` "i•4''t_. "'AA,rr, .r. 7?it......T : �i3 Fri l 'z . •• , ,
:":.. Q, gala •..
Assessment/ ,,r . r '`4
Emergency Z $26.96 S.66 $18 88
t'M %
Level Rate i
r J,' '!
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE.OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY A/G�REFMF:NT +� /
✓r� (!fl ,
THIS AGREEMENT is made and entered into this day of 20
by and between the Board of County Commissioners of Weld County,on b Calf of the Wel
County Department of Human Services. whose address is P.O. Box A,Greeley,CO, 80632,
hereinafter referred to as,"County."and Froggatte,Samuel and Rachelle,whose address is 213
N 52nd Ave,Greeley,CO 80634, hereinafter referred to as,"Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS,the Colorado State Department of Human Services(hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home(hereinafter referred to as"Facility"),and
WHEREAS,Contractor understands and agrees that it must,during the term hereof, hold
a valid certificate/license for the Facility,maintain certification standards,and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department.and
WHEREAS.County may, but shall not be obligated to,purchase foster care services,and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW. THEREFORE, in consideration of the mutual promises and covenants made
herein.County and Contractor agree as follows:
1. TERM:
A. The term of this Agreement shall be from July 1,2014,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 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. AGRLEMENTS 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
pro%tiler.
t'WS-7A Individual Provider C'ontrart ! Revised 0"v!4
,2 /5—A 7(5)
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 tluman
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
supers king agency.
C WS -1 Individual I'ri, idea Contract Revised __`l 4
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(HFPAA).
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
taws 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 5500.000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
C'ws A Individual Provider Contraci Revised 66'2ut4
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.
u. 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 Stale Department of i[Liman
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.
(`W'S-7A indhiduat Provider Contract 4 Revised 6.20 i4
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 fur 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.
t. 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 betv,een
the parties hereto and relating to the care and services herein described_
E. The State of'(olorado Department of Human Services shall be and hereby is
permitted to monitor service program. fiscal and other records ,,ufficicntly to <t :,tire
!'\5'S-7;, Inth', dual l'inAider Contract Revised 52014
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 live 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:
. 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) aboNe
4. Have not within a three-year period preceding this Agreement, had one or more
(WC-7 Individual i'ro.,drr C nntraci 6 Revised/,n.};4
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.
I'. 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 ot'such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit ofcreditors.
and filings in bankruptcy.reorganisations and/or foreclosure.
� VS-7A Individual Provider Contract Reused 6%7014
WHEREFORE,the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County,on behalf of the Weld County Department
ATTEST: d.„,1,4, �� of Human Services
/
By: B •
Deputy Ce, rk to +J7 arbara Kirkmey r, Char
ONTRACT 1 R:
Approval as to Subs ce K:',? 1
WELD COUNTY P :tgX :'tl ggatte, Samuel and Rachelte
OF HUMAN SERV ± ``-=� 3 i`152nd Ave
` 0' AJrceley,CO 80634
By AL . , ' �.� By:
my Di tor' ! desi_' ee's) Contractor's(or d i n gnature
i•.natu • d Date 4 and Date
By:
ntractor's(orcesignee gnature
and Date
('WS-7A Individual Provider Contract 8 Revised 6/20 I
c>2.0/5— �O 7 (O--)
•
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 Froggatte,Samuel and Rachelie, 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# 1601426. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 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 tollowing the month of service. If the
reimbursement request is not submitted within twenty-true(25)calendar days of
the month following service. it may result in forfeiture of payment.
CWS•7a Individual Provider Contract Revised 6/2014
•
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 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.
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 arc 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 t Iuman 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 MSC,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
C«l'•-11 Individual Pro,.uier Contract iccd 62014
.« .,. . ,.. :.may...,. ,., ..�. •
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 i4 days and dental examinations
completed within K 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.
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
1 1. 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 ohutinine, attempting to obtain.of perh,nning
CWS-7.A Individual Prcnidcr Contract 1 I Revised h^G i 4
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.
CA VS-7A Individual Provider Contract Revised C"2614
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.
Pt. 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 elan?
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 oRen 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?
PS.how much time is the provider required to assist the child because of impairments beyond aze 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 therapy services needed to address ' 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
o Medical Needs-(1 f condition is rated"severe".please Select One
• complete the Medically fragile NBC')
�T Emancipation Select One
Eatit2g Problems — Select One
Boundary Issues Select One
Requires Night Care Select One
Education Select One
involvement with Child's Family Select One
E xhihit B to the Additr.mal Pro),i i n i Revised 6.20!-I
F:\I11RI1 (
Weld(ounty Departtnent of Human Service
Needs Raced Care
Rate Table
(Effective 7/01%2014i
,
.
-..:f' ...a.
-_,� '.;, Si2.14 1 50.00
Chanty Basic Age U-ID...S16.7j : 5.!6 No crisis intcrvenliun.Minimal 's
Ntalntenaace Age I 1-14...SI8 50 Not needed or ccscr •-' •• •—
t:' CPA involvement,one face-to-
Rate F.-• Age 15-21...514.15 '„r. `' under Medicaid. -•
face visa with child per month. .6
':f 515-51 55.05
c Minimal crisis intervention as Regularly Scheduled
2 22S20' Y'J. S.66 treaded.one fm:c-to-tale visit therapy up to$ 5' ''t
;:F per month with child,2-3
cm a hours:m 'h,
ix-intact,per month
,c
14 1 S23.59 _.,
R S rat, S17_ly `- .......__ - •-------•--
e
SfR.8lt 510.11
-` ` Occasional crisis intervention as -•`,`- Weekly scheduled
2 ,.s.: 526 9n S 66 :; needed.two lace4o-face visits it therapy 5.8 hours a $4.8')
,'4 f' • - with child.2-3 contacts per month with 4 hours of ':i
month group therapy.
•
2 ,t s lit: t 5.66 S20.56 ---- ------
S22.14 $15.16 ''
•
j 4 Regularly scheduled i` 5
.'-^ ':` Ongoing crisis intervention as c'''•
weekly.multiple :'',3
f needed,weekly face-to-ace
1 `,i S?? '0 ., 5.66 sessions,can include SA 1')
visits with child,and intensive ;-.
merethan I person
. 1 coordination of multiple '.
. i.c.family therapy, 'for :..
.:t services 9-12 hcncralmtmlhl}. ;
ic+ ..'.4 t fc
.g
3 i/2 i^1 Si-7.Ott 51.6 S23.93 --------- ----------
C •
r.
'X: S25.61 C.4.44.'44.4-
if3�.. 4'.S �'r+ S"
'.•.aj Ongoing ens-Is intervention as ,,y�.4
•
,r i ''..4 needed,which includes high :R7 ..
Hl ( I S I II k S level ul cask managenknl and — hcgntistcII
Drop Do»n ` ('PA involvement with child and J�
K' • provider and 2-.3 face-to face '.
contacts per week minimum tA
•
l '''1 : .:43_ ; ' •. .:�f+?5t"io.4r ty1"Ci�'T..w -_ �nr-p ,fir,.,'.`1, •.•q�il7s -'.h"�" (;.'"'=';'...!.':17Z1
_„7 a.
is ds73�r} ,f:R �L.5, aC+a i:≥ ..4a c:+ , ,.,. a...� -,•,:;.. -
.�d iw....,r...jC�� - a �a�r:i:� d3 t ro: , to I .•.. Y`°K'
' 2• k;-2
is>rs.menti r.'
l'mert enrs 1� 526 9, S.b!• '.16 48 __...._.._
4
0
I.r%el Rate00,
..
Exhibit C to the ldditionuil Provision, , 1 Rcv i>ed 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
iv'
THIS AGREEMENT is made and entered into this day of (:)(LTOSE.2..-. 201 ,
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%V
23rd Street Dr.,Greeley,CO 80634. hereinafter referred to as."Contractor." This Agreement
covers all children placed by County with Contractor.
W ITN ESSETI 1:
WHEREAS, the Colorado Slate Department of I luman Services(hereinafter referred to
as"State Department"). has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter I ionic (hereinafter referred to as"f=acility").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 fhstcr care services,and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW. THEREFORE, in consideration of the mutual promises and covenants made
herein,County and Contractor agree as follows:
i. TERM:
A. The term of this Agreement shall be from July 1,2014,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. II'notice is so given. this Agreement shall terminate upon the expiration
of thirty(30)days. or until the eligible children) may he placed elsewhere,
whichever occurs first.and the liability of the parties hereunder firr 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.
C' S•7:k Individual Provider Contract I Revised 6!20 1 0��(6')
D /
fJZcg(49
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 hisiher 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 10 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.
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.
E 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.
C'WS-7A Individual Provider Contract '_ Revised 6:2014
i. Any intbrmation 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 m ith and abide by all rules and regulations of the Colorado
Department of Human Services. the Colorado Department of I lealth Care Policy
and Financing(if appropriate), the State of Colorado and any applicable federal
laws and regulations, as such, which may he 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 6''_014
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.
2K. 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 tier 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 fir the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. .fn 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.
K. 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.
('WS-7A Individuai Provider Contract 4 Revised 6.2014
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 he and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
C'µ'S-7A Individual Provider Contract 5 Revised o:20 14
the purchase of services in this Agreement arc carried out thr the benefit of the
atbrementioned 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 he 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 hut 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 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. 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 he 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 (I3)above.
4. Have not within a three-year period preceding this Agreement, had one or more
(.'WS-7A Individual Provider Contract 6 Revised'2014
public transactions(federal state.and local)terminated flan 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 tailed to satisfy the scope
of work found in this Agreement.txhihit 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 satist tetorily completed.
2. Deny pay ment or recover reimbursement fir those services or deliverables which
have not been perfirrmcd and which due to circumstances caused by Contractor
cannot he perlbt»tcd or if perft nncd would he of no value to County. I)enial of
the amount of payment shall he 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 he
strictly reserved to the undersigned panics or their assignees.and nothing contained
in this Agreement shall give or allow any claim or right of action sshatsoeser by any
other person not included in this Agreement. It is the express intention ul the
undersigned parties that any entity other than the undersigned panics or their
assignees receiving services or benefits under this Agreement shall he an incidental
beneficiary only.
I'. \o portion of this Agreement shall he 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 cirenmvem 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 pray ided 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 documents)to the County
Director. The term"litigation"includes an assignment for the benefit of creditors.
and filings in bankruptcy.reorganizations and or lorcclosure.
('vs S-7.' Indisidu,d Pro%rder Contract 7 Rcsiscd C.=U14
WI IERLFORE. the parties have herein set their hands and affixed their seals the da. and
date tirst written above.
COUNTY:
The Board of County Commissioners of Weld
C ounty,on beha lfof the Weld County Department
ATTEST: d
. of E�uman Services
I .
By: y✓�ti . 1
Deputy C�rk to +! `' ....._.„,.a Barbara Kirkmeyer, Chair apR 1 3 2015
et16t
Approval as to Substay, r; C
W LLD COUNTY DE�, l r. tzzle. Phillip and Nicole
O I It WAN SERVICE, J? X80 W 23rd Street Dr.
44. �Li . ,-Greeley.CO 80634
sv
I3y:.J • "�� - > By:: ..--------;..--------; r O 1aC' u ty ircr or s(or ' signee' Col tractor's o designees) Siam\ciA\ore
S an ture an Date I and Date fly: r O176-actor's(or signcc' r ignat ire
and Date
C'WS-7A Individual Provider Contract 8 Revised 6 2014
070/j----/47(6)
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
I�APPROVED AS Ol.�lN__�
-20
Controller (/
AP r ' ,J OF. ' .
Cou d'ttorney
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 as Exhibit B. shall he 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'Fable,designated within this exhibit
as Exhibit C, for children placed within the Weld County Certified Foster Care I tome
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 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
he release to Contractor.
4. Any additional costs for specialized services, which may include but arc 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 nut 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. lithe
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 6'2014
C. Placement service reimbursement shall he paid from the date of placement up to,
but not including the day of discharge.
D. fransportation 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 (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 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 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
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.
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
pertormance arc satisfactorily completed:
R. 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 he performed or if perthrmed would he 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 1 lumen 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 6/2014
administrative agency.shall deliver copies of such doeununtts)to the I lwn.tn tier ices'
Director. the term"litigation"includes an assignment for the benefit ofcreditors,and
filings in bankruptcy.reorgani/ations and'or foreclosure.
CONTRACTOR SHALT.:
I. Attend or participate in family Engagement or fcam 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 ifeonsidering giving notice to remove a child.escept in emergency
situations. These requests shall be made through the child's caseworker and:or the
C'ontractor's Foster Care Coordinator.
Actively participate in achieving the child's permanency goal.cooperate with any
contractors hired by Weld County Department of I Inman Scr ices or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate.and comply with the treatment plan ol'the child.
4. I lave 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 des eloped regarding
the child in order to promote educational success.
o. Immediately report to the Count) Department and or local law enliircemcnt 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 lIDUS.
8. Read.he lamiliar with and agree to the terms and conditions as set forth in the I .ter
Parent Ilandhook which can he accessed through Ill IS.
�). Naintain.update information in the foster child's binder. I he hinder gill he reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Con rdinator.
I tt. 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 lair each
child.
I 2. Assure and certify that it and its principals:
A. Are not presently debarred.suspended.proposed fur debarment.and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
II. Ila►e 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
C ws•7A Individual Pro%idcr Contract I 1 Ito ised i 2014
a public(federal.state.or local)transaction or contract under a public transaction:
violation of federal or state antitrust statutes or commission of 4tubeiilement.
theft.forgery.briber). falsification or destruction of records.making false
statements.or receiving stolen property:
[ Are not presently indicted bite or otherwise criminally or civilly charged by a
government entity (federal.state.or local)with commission ol'any of the offenses
enumerated in paragraph(HI above.
D. 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.
13. l'ompl) with all County and State certification requirements as sat forth in the Slate
Department rules,Staff Manual Volume VII and the Weld County Department of l luman
Services Policy and Procedure manual.
l'N S-J:\114111%1(WProvider Contrail 12 Robed h 201F
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.
PI. How often does the child require transportation by the foster care provider for the following: Select One
I herapy:Medical Treatment; Family Visitation:Extraordinary Educational Needs:etc.,as outlined •.L J��h
_ in the treatment plan? 7 I
P2. How often is the tipster care provider required to participate in child's therapy or counseling Select One /
sessions'' \"i-- —7 i,..•C• "ti'—
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? µl!}
P4. F 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. I Iot% 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.How often are thera v services needed to address child's individual needs •er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
I— Assessment Areas: Comment: Rating:
❑ Aggression'CTuelty to Animals Select One
❑ Verbal or Pli sisal 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'lncopresis Select One
❑ Runaway. Select One
Sexual Offenses Select One
^
Lj Inappropriate Sexual Behavior Select One
rE____H-3 Select One
Disruptive Behavior I _
Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
Medical Needs-t If condition is rated"severe",please Select One
❑
complete the Medically fragile N13(•)
LE Emancipation I Select One
❑ Eating Problems Select One
4Boundary Issues _ Select One
Requires Night Care Select One
❑ Education Select One
Involvement with Child's Family Select One
Exhibit 13 to the Additional Provisions 13 Revised 6.'2014
LXIIIRI I
Meld County Department of Human Service
Needs based('are
Rale Table
(Effecti,c 7/01/2.01-$1
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I:dohit c to the-Situ iti.lnal Pros'stints I-I Res iced 6?1114
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this day of p\)bU 2014-
by and between the Board of County Commissioners of Weld aunty, 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 Hartness, Richard and Marlaena,whose address is
15716 CR 40, Platteville, CO 80651, 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
I lome/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services,and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014, 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 he 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.
c).761,5---/007(12
CWS-7A Individual Provider Contract I Revised 6/2014
RROOar
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 3 Revised 6/2014
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 6/2014
• 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 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 6/2014
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.
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 ofa 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 he, 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 6/2014
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.
I.. 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
CWS-7A Individual Provider Contract 6 Revised 6/2014
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 he 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�',S-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
AT'TFs r: .g,k of Human Services
By. By
Deputy lerk to ,� } �,,,f , Barbara Kirkmeyer, Chair 1 3 2015
"2.1),S, 'ONTRACTOR:
Approval as to Substa tffi1 kYiy tki'/
WELD COUNTY D A rp artness, Richard and Marlaena
OF HUMAN SERVI 1",,, 4��715716 CR 40
(J,,1j r .r ks '✓ Platteville, CO 80651
By ._/ \,l,L By:
C u ty Direc or's (or d. signee's Contractor's (or designee's) Signature
S(gn tare an Date and Date
By:it_ O6(ii
Contractor's (or designee's) Signature
and Date
020/�= /60 7(1)
CWS-7A Individual Provider Contract R Revised 62014
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
ft 'APTOVEASfiO NNG:q
llJ l7
Controller
• FO:
Cou ttorney
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 Hartness, Richard and Marlaena, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
I. 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# 1643348. 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 arc 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 6/2014
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 shah
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 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 612014
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'Yearn 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.
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 II Revised 6/2014
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. Arc 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 6/2014
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 toster 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 tlt_e.provWel 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 theca. services needed to address hila's individual needs •er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas; Comment: Rating: i
❑ y Aggression/Cruet to Animals l Select One
1 ,9
❑ Verbal or Physical Threatening _ Select One
❑ Destructive of Property/Fire Setting - _ Select One
❑ Stealing Select One
❑ I Self-injurious Behavior Select One
❑ Substance Abuse Select One •
❑ Presence of Psychiatric Symptoms/Conditions _ Select One
❑ Enuresis/F.ncopresis Select One
❑ Runaway Select One •
D 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
E . 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
EXI{IBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
tit>tVI
' •�r .Ys aT I.i, 1 ( a �. 7 var s Fs.. "t _ f
t. 7.• 430
IT ,4t +'- G.+e..1''
,.a '- > .'. ✓.bl �2ddEF i'.d�a,sa'S"' ��c �. i 1 •, .. k' WLtT �-
'max . f � Ce' '' .;, s-
-4 d -4' >D 1 5' , /: -.'i `44".5y 1 .- -S f'4-.r•C'� r - 1 .,,i i,l� '5,,
,,,,....,,
: . 3� ,..,.... .1. ..t.....,,,...„.. ..4.,,,.,::-?.„iFF ' s + " �' . 'Acs r wra
.„,.,
'; $12.14
County Basic Age 0-10...S16.73 _ $0.00gll
$.i 6 No crisis intervention.Minimal
Maintenance Age 11-14...S18.50 ' Not needed or cover
B ;;a
roi CPA involvement one f -to- -
Rate ?,. Age 15-21...$19.75 g zE under Medicaid.
"ii_, P.i. face visit with child per month. ,leg
41,4
4 $15.51 $5.05
"® ". -5,, '. Minimal crisis intervention as i
1 z s $20.22 $.66 needed,one face-to-face visit Regularly Scheduled $3.39
!, therapy up to 4
{fi ' per month with child.2-3
hours/month.
-` contacts per month :;
��
I /, $23 54 $.6b $17.19 --- - `.'f
1 zs:r x
$Ig.ag s10.il
i Occasional crisis intervention as , Weekly scheduled
2 2f)90 $.66 needed.two face-to-face visits therapy 5-8 hours a $4 S9
i A
iNIP with child,2-3 contacts per month with 4 hours of
month Z.',' group therapy.
— 6W4tt4iE
2'4 .'i $30.33 m $.66 $20.56 ------ ------
'-~ 1 $22.24 $15.16
_;, --.--r • Regularly scheduled "-
c.,° Ongoing crisis intervention as i
,; t g week`-y,multiple 4
3 $ 70 5.66 ; needed,weekly face-to-face er, ,<;
sessions.,can include
i.
visits with child,and intensive a,: more than 1 person. ar.
coordination of multiple y �*'
:R, i.e.family therapy.for w
services. 0 9.12 hours/monthly. '
3 1/2 $ 74I( $hG $23.93 45 --------
'1K-, -. ._.... $25.61
Ongoing crisis intervention as 3 tH1 ,
4 a: s needed,which includes high '-: w
RCCF $4) 11 S 66 level of case management and 44 ,.,', Negotiated
Drop Down - ('PA involvement with child and
.' provider and 2-3 face-to face
ycontacts per vwcek minimum Pri
w. xZw�'x:-L "� i�.5IW...,-* o:d�i3{ Mf,< .... '! v Ka;f -,a. -,, --.:.
Assessment' 1 <a. -
Emergency ,'''',1 $26 W3, $.6h $IR.RB 4i.,
VileLevel Rate _ ,
Exhibit C to the Additional Provisions 14 Itreiscd 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
Tif
THIS AGREEMENT is made and entered into this /c7 clay of /L- , 20/61
by and between the Board of County Commissioners of Weld County, on behalf of the Weld
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Heard,John and Kimberly,whose address is 109
Hunters Cove Dr., Mead,CO 80542, hereinafter referred to as,"Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services(hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as"Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, 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.
O2.O75-- /O 07 (1)
CWS-7A Individual Provider Contract I Revised 6/2014
FH1 6O%&
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 6/2014
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.
CW S-7A Individual Provider Contract 3 Revised 6,2014
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 6/2014
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
shalt 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 6/2014
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 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. 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
CWS-7A Individual Provider Contract 6 Revised 6/2014
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 tents 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 6'2014
WHEREFORE,the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: ds,& W ;oe of Human Services
1 ..”.„,- lex_LAIASIA---
Deputy erk to ��:�• ` Barbara Kirkmeyer, Chair i 1 3 2015
Cx•F \� ' - NTRACTOR:
act ,<<2
Approval as to Substan ^
WELD COUNTY DEP rs T Aga hard, John and Kimberly
OF HUMAN SERVICE 1fi/ c3 `c\ ,r,J 49 Hunters Cove Dr.
Mead, CO 80542
By W-- , By: ( / i`� //
C ty Dire tor's (or esignee s) Co actor's(or de ignee's) Signature
Si ature an Date an Date
�g�
By: & / //ee / /0/4d
////
Contraks(or designee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
OZO/5—/oO 7(g)
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
APP OVED AST FI7
L ail/24a
Controller
AP"7% • FO .
Cou .attorney
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
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# 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
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 6/2014
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 6/2014
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 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 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 6/2014
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 6/20
EXHIBIT R
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.
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
i 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 provides 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,battling,grooming,physical,and/or occupational therapy?
rAl. 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
i 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: I Rating:
❑ AggressioniC'ruelty 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
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)
E Emancipation Select One
❑ Eating Problems Select One
❑ Boundary Issues Select One
0 Requires Night Care Select One
❑ Education Select One
3—�Involvement with Child's Family Select One 1
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)
a ri ` rF
$12.14
County Basic Age 0-10...$16.73 $,66 No crisis intervention,Minimal $0.00
Maintenance - Age 11-14...$18.50 Not needed or cover µ
Rate ,�V Age 15-21...$19.75 CPA involvement,one(ace-to- under Medicaid k
v=.de face visit with child per month
$15.51 $5.05
4 A t Minimal crisis intervention ac "r; Regularly Scheduled
I $20.22 $.66 a.. needed,one face-to-face visit '�W therapy up to 4 $3.39
per month with child,2-3 hours/moo nth rtf.
ffi contacts per month ;
•y
$23.59 166 x $17.19 . ---------
7z. $18.88 $10.11
Occasional crisis intervention as Weekly scheduled
$26.96 $66 needed,two face-to-face visits7 therapy 5-8 hours a $4.89
fi with child,2-3 contacts per month with 4 hours of
t° - month group therapy.
2 R a'' $30.33 - $.66 $20.56 ,,,
'. $22.24 $15.16
xr': Regularly scheduled S
;+ t Ongoing crisis intervention as - weekly,multiple
3 'Z $33 70 $66 +: needed,weekly face-to-face sessions,can include '...,1 $6.39
visits with child,and intensive more than I person.
coordination of multiple ry", i.e.family therapy.for
services. 3 9-12 hours/monthly. 'sue
fir' 3
31/2 $37.06 $.66 • $23.93
. $25.61
x± ,. Ongoing crisis intervention as ,,: ''
4 t ,51:7,. needed,which includes high
r'`•t . 4 Negotiated
RCCF $40.44 $66 level of case management and 8
Drop Down 7:,..:: , CPA involvement with child and
Oa: provider and 2.3 face-to face 74
contacts per week minimum.
`-
Assessment/ -
Emergency $26.96 $66 b:+ $18.88 -------
Level Rate r5..
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this /Li y of eg/ , 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 Heiner, Sara, whose address is 3000 W 19th St,
Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all children
placed by County with Contractor.
WITNESSETH:
WHEREAS,the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as"Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, 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.
oZo/,--/oo70)
CWS-7A Individual Provider Contract 1 Revised (v2014
v'�4 11` fi)
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 6/2014
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 ntle.
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 tent 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 S500,000 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 6/2014
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 6/2014
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.
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 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 6./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
C WS-7A Individual Provider Contract 6 Revised 6/2014
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 6/2014
WI IEREFORE,the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
,� County, on behalf of the Weld County Department
ATTEST: ' of Human .Serrvices
By: _ L�(J By:3dA14) 4 .__
Deputy C rk to thefl Barbara Kirkme er, Chair
` C.?ji` ;;4 y R 13 2015
F /
` f ONTRACTOR:
Approval as to Substa � �_.�
WELD COUNTY DE it r X I I tler, Sara
• „Y 1
OF HUMAN SERVIC ae 00 W 19th St
t 3ti reeley, CO 80634
By: !) j _____LL By. <N1O-ASS
Co y Directors (or desig ce's) j Contractor's (or designee's) Signature
Si m ure and to and Date
By: -
Contractor's (or designee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
r�26/s' /0o7(9)
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
APPROVED AS O FLING•
_LahAka
C gyp®
Controller =
APE FO
Cou ttorney
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
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# 1547292. 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 6/2014
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'
CWS-7A Individual Provider Contract 10 Revised 6/2014
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.
I I. 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 6/2014
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 6/2014
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 tipster 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
coniunction with a regular or special education plan?
P4. flow often does the child require special iii,l 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 therapy services needed to address child's individual needs cr 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)
O Emancipation Select One
❑ Eating Problems Select One
Boundary Issues Select One
Requires Night Care Select One
O Education Select One
❑ Involvement with Child's Family Select One
Exhibit 13 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)
LEVEL OF CHILD• ADMINISTRATIVE ADMINISTRATIVE, MEDICAL
SERVICE MAINTENANCE RESPITE MAINTENANCE SERVICES NEEDS
Level Daily Rate Daily Rate:; Daily Rate Daily Rate Daily Rate
SI2.14
County Basic Age 0-10...S16.73 SO.00
S.66 No crisis intervention,Minimal
Maintenance Age 11-14...S18.50 Not needed or cover
CPA involvement,one face-to-
Rate under Medicaid.
Age 15-21...S19.75
face visit with child per month.
S 15.51 S5.05
Minima!crisis intervention as Regularly Scheduled
1 S20.22 S.66 needed,one thee-to-thee visit S3.39
therapy up to 4
per month with child.2-3 hours/month.
contacts per month
1 'A $23.59 S.66 S17.19
._ S 18.88 S10.11
Occasional crisis intervention as Weekly scheduled
2 S26.96 S.6c' needed,two face-to-face visits therapy 5-8 hours a S4.89
with child.2-3 contacts per month with 4 hours of
month group therapy.
2 Yz S30.33 $.66 S20.56
S22.24 515.16
Regularly scheduled
Ongoing crisis intervention as weekly.multiple
3 S33.70 S.66 needed,weekly thee-to-face sessions,can include $6.39
visits with child,and intensive more than I person,
coordination of multiple i.e.family therapy,for
services. 9-12 hours/monthly.
3 1/2 537.06 S.66 S23 93
— � S25.61
Ongoing crisis intervention as
4 needed,which includes high
RCCF S40.44 S.66 level of case management and Negotiated
Drop Down Cl'A involvement with child and
provider and 2-3 face-to face
contacts per week minimum.
Assessment/
Emergency S26.96 5.66 SI 8.88
Level Rate •
Exhibit C to the Additional Provisions 14 Revised 612014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
�A !L_, 20/b
THIS AGREEMENT is made and entered into this�,3 day of ,
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.
W ITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, 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. 6 .2D/5— /OO 1`'/,
0)
C WS-7A Individual Provider Contract l Revised 6/2014
a IROOSCo
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.
C WS-7A Individual Provider Contract 2 Revised 6/2014
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 S500,000 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 6/2014
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 6/2014
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 6/2014
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
ally 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
CWS-7A Individual Provider Contract 6 Revised 6/2014
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 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
tfid I. County, on behalf of the Weld County Department
ATTEST: of Human Services
By: By
�(Gl e 2 /A
Deputy C rk tot e BoaF. - Barbara Kirkmeyer, Cha r 'R 1 3 2015
. ti
'v x'74-' ICONTRACTOR:
Approval as to Substan+
WELD COUNTY DEP ft 1p�rnandez, Roberto and Margarita
OF HUMAN SERVICk e"' �``'9__i 2 Elm Ct
t.,,lzort Lupton, CO 80621
p
C u ty ire is esignee ) Con rac or's(or designee's) Signature
S gi ature an Date 1 and Date
By. /�.kor ��es= n 10 ���
ontr ctor's((or desiggnee's igna re
and Date
O2 760)
CWS-7A Individual Provider Contract 8 Revised 6/2014
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
APPROVED AS TO UN ING:
Controller
APP • O' ' .
Coun; torney
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 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# 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 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 6/2014
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 JO Revised 6/2014
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.
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. 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 6/2014
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 6/2014
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.
Pt. 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. [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. 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 therapy services needed to address child's individual needs .er NBC assessment'? Select One I
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/C'ntell_y to Animals Select One
—❑ Verbal or Physical Threatening Select One
❑_ Destructive of Property/Fire Setting Select One
71 Stealing _
Select One
D 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
O 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
8 Boundary Issues Select One
Requires Night Care Select One
O 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)
LEVEL OF i.::-CHILD ADMINISTRATIVE ADMINISTRATIVE MEDICAL
•
SERVICE MAINTENANCE RESPITE. MAINTENANCE SERVICES NEEDS
Level Daily Rate Daily Rate Daily Rate Daily Rate Daily Rate
•
512.14
County Basic Age 0-10...S16.73 $0.00
$.66 No crisis intervention,Minimal
Maintenance Age 11-14...SI8.50 Not needed or cover
CPA involvement,one face-to under Medicaid.
Rate Age 15-21...S19.75
lace visit with child per month.
S15.51
55.05
Minimal crisis intervention:IS Regularly Scheduled
1 S20.22 `)c,r, needed.one face-to-face visit .
therapy up to 4
per month with child.2-3 hoursimonth-
contacts per month
I 1., $23.59 5.66 S17.19
1
518.88 S10.11
Occasional crisis intervention as Weekly scheduled
2 S26.96 S.66 needed.two face-to-face visits therapy 5-S hours a S4.89
with child.2-3 contacts per month with 4 hours of
month group therapy.
._2 ', S30.33 $.66 $20.56
$22.24 S 15.16
Regularly scheduled
Ongoing crisis intervention as weekly,multiple
3 S33.70 S.66 needed,weekly thee-to-face sessions,can include $6.39
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_ $37.06 ',66 S23.93
$25.61
Ongoing crisis intervention as
4 needed,which includes high .
RCCF S411.44 �,(,(, level of case management and Negotiated
Drop Down CPA involvement with child and
provider and 2-3 face-to face
contacts per week nunimum.
Assessment/
Emergency $26.96 S .)(7 S18.88
Level Rate .
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this 5 day of )k-• 1, 20 i4,
by and between the Board of County Commissioners of Weld County, on belikilf 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 Colorado State Department of Human Services(hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home(hereinafter referred to as"Facility"),and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department,and
WHEREAS,County may, but shall not be obligated to,purchase foster care services,and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW,THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014,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 children)may he 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:
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 6/2014
0Zp/�-/OD 7(rl)
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 6/2014
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 S500,000 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 6/2014
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.
R. 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. "1'o 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 6/2014
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 6/2014
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 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 be in accordance with the policies, procedures,and practices olCounty.
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 6/2014
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 arc 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 6/2014
WHEREFORE.the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County,on behalf of the Weld County Department
ATTEST: d� J e'C. '(X- of Human Services
BY
Deputy C k iCfnui"ff Barbara Kirkmeyer, Chair •R 1 3 2015
4 \ CONTRACTOR:
Approval as to Subs yYYq ;"
WELD COUNTY Hoeft, Kimberly
OF I IUMAN SERV 4 /720 E. 3rd Street u; ,fr Eaton, CO 80615
•
By: � ti - By: 74_ 9 5 /
Co ty Direc r s(or a signee Contractors signee s) Signatu
SI n ture and ate and Date
BY __..
Contractor's(or designee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
�a/� /0e)7 6O
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
APPROVED PR AS T F�NG:
Controller
APS 0 .
Cou torney
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 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 I lome
identified as Provider ID# 1603004. 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 arc 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. It'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 Rcvised 6/2014
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'
CWS-7A Individual Provider Contract 10 Revised 6/2014
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 ot'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.
l0. 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. 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 6/2014
•
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 (13)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 6/2014
` 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. -
PI. 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.
TI.How often are thcra.v services needed to address child's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT)— Behavioral Assessment
Assessment Areas: T Comment: Rating:
O 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 L Select One _
Substance Abuse Select One
Presence of Psychiatric Symptoms/Conditions Select One _
REnuresis/Encopresis Select One
Runaway Select One
Sexual Offenses Select One _
Inappropriate Sexual Behavior _ Select One
Select One
Select One
Disruptive Behavior
Delinquent Behavior
Depressive-like Behavior Select One
O Medical Needs-(If condition Is rated"severe",please Select One
complete the Medically fragile NBC)
❑ P
Emanci ation 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 i
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)
. - z,v• -T ' : .40;Rw?r i ! �{ r ` r �
LEVEL L O]� CHILD 2„ \Dmm,rig ,w �k x :i1 ]!1 s � }'FEAIt °T
u �;r
Si R\1(..F. \t 11A1TE\ANCkr 6' :.-',Q7'14....4.11-7'-.}'-:: \]rl]lsii + lYCF f�; i q -- ; '} wN•Ep5`it;'
i 4I Daii-',:1:47.1 -;-.- 1
iiti ke �D v e, D ), # Ave' 'r pried, to
.__ __ ;;Y-41'"::'..t7: n F li t' 71 r.ut q ,r L ..
$12
.14 Basic Age 0-10...$16.73 .I4 $0.00
x.66 - No crisis intervention.Minimal
Maintenance Age I I-I4...Sl8.50 Not needed or cover
Rate Age 15-21...S19.75 CPA involvement,one face-to- under Medicaid.
face visit with child per month.
$15.51 05.05
Minimal crisis intervention as Regularly Scheduled
1 $20.22 5.66 needed,one face-to-face visit $3.39
therapy up to 4
•i per month with child,2-3 hours/month.
contacts per month
MT
1 ';S $23.59 ! ' $.66 C 517.19 ]T -----------
?,.
$18.88 510.11 •
!, Occasional crisis intervention as . Weekly scheduled
114
2 $2(1.96 5.66 needed,two face-to-face visits 1 therapy 5-8 hours a 5,.89
• ` F with child,2-3 contacts per t+ month with 4 hours of
`+ month group therapy. •
2% $30.33 5.66 ;Q=. $20.56 ----------
+ $22.24 `.' $15.16
x.*
Regularly scheduled f
Ongoing crisis intervention as , :'
weekly,multiple .
3 .;-- 533.70 5.66 ;} needed,weekly face-to-face sessions,can include 56.34
'! ' 4 visits with child,and intensive •'A,
=,ii sc;': more than I person,
- tk coordination of multiple
i.e family therapy,for
services. 'f,::,.4. ":•
7',;::,. 9-I2 hours/monthly. ,. ,,;_
WO
3 1/2 ;ss $37-06 i. 4.-;11 1 $23.93 , ' --------- -$.G6 ;1�;1.
• _. $25.61
Ongoing crisis intervention as '%r'
4 _' sc needed,which includes high '
RCCF 't: $40,44 $-66 level of case management and Negotiated
Drop DownCPA involvement with child and 1314, •
•;7•:4:: ft";-. provider and 2-3 face-to face
._ _ ;x
t1-- ev contacts per week minimum.424 t_- fir
Assessment/ .,, s
Emergency 7'-- $26.96 fir;;: S,66 $18.88 =1 ---------
Level Rate . r,;:: ;_,
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this 4+.1"‘day ofOG+r h.14. ,20 I'~f ,
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 Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as"Facility"),and
WHEREAS, Contractor understands and agrees that it must, during the term hereof,hold
a valid certificate/license for the Facility,maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department,and
WHEREAS, County may, but shall not be obligated to,purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW,THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014, 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.
020/-/O07 (/x)
CWS-7A Individual Provider Contract 1 Revised� R 6/2014
6/
1 I Dac
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 6/2014
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 6/2014
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 6/2014
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 6/2014
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:
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
CWS-7A Individual Provider Contract 6 Revised 6/2014
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 6/2014
WHEREFORE,the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
diritiAl
County,on behalf of the Weld County Department ATTEST: Gs ;vi of Human Services
J • LBy ., ByF4 2 1�i,.. k.it,p�--
Deputy lerk t 44, .fJi , Barbara Kirkmeyer, Chair APR X 3 2111
; : \CONTRACTOR:
Approval as to Subst'. ' ^.,:\
PP :...4„.., :\ .i
WELD COUNTY D �(irchoefer,John and Erin
OF HUMAN SERVI /�} ,"�t -3.4:x2224 Scarborough Court
°,- Ltd '`zj{ 47 Fort Collins, CO 80526
h
By: t)(/ _ L,U,`J By: /i, t(. f -1.-
C ty Direct r s(or d ignee 76/tract r (or signee s) Signature
Si uture and ate a d Date
7 -7
By: ', ,;
Contractor's(or esignee's) Signature
and Date J7
o20/ /et7(i.)
CWS-7A Individual Provider Contract 8 Revised 6`2014
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
APPROVED AS 0 FING:
a4,62
Controller
APS FO .
Cou •ttorney
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
I. 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# 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 9 Revised 6/2014
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 6/2014
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 6/2014
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 6/2014
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 regular or special education plan?
P4.How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitorinj of 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?
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
O Sexual Offenses Select One
❑ 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
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
LEVEL OF CHILD - ADMINISTRATIVE ADMINISTRATIVE MEDICAL
SERVICE MAINTENANCE RESPITE MAINTENANCE:_ SERVICES a NEEDS
ice'
{
Level '• Daily Rate �`Daily;Rate -. Daily Rate Dat13+Rate Daily Rate
County Basic Age 0-10...$16.73 $12.14 $0.00
5.66 No crisis intervention,Minimal
Maintenance • Age 11-14—$18.50 Not needed or cover ---------
Rate Age 15-21...$19.75 CPA involvement,one face to under Medicaid.
face visit with child per month.
$15.51 $5.05
n
Minimal crisis intervention as Regularly Scheduled
I $20.22 _ 5.66 needed,one face-to-face visit ', therapy up to 4 $3.39
per month with child,2-3
hours/month.
contacts per month
1'/3 $23.59 $.66 �' $17.19 ------
$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 $4.89
-,71
, =f•LI _ with child,2-3 contacts per month with 4 hours of -
month group therapy.
2%, $30.33 5.66 S20.56
i.
S22.24 $15.16
Regularly scheduled
Ongoing crisis intervention as • weekly,multiple
3 533.70 5.66 needed,weekly face-to-face sessions,can include $6.39
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 $37.06 S.66 $23.93
$25.61
Ongoing crisis intervention as
4 needed,which includes high
RCCF $40.44 5.66 level of case management and Negotiated
Drop Down CPA involvement with child and
_ provider and 2-3 face-to face
contacts per week minimum.
Assessment/
Emergency $26.96 $.66 $18.88
Level Rate
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this /I day of fh,(y(.(,r1�, 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 Land, Brad and Molly,whose address is 1831 25th
Ave, Greeley,CO 80634, hereinafter referred to as, "Contractor." This Agreement covers all
children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services(hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as"Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards,and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster I-lome issued by the State
Department, 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 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:
1. TERM:
A. The term of this Agreement shall be from July 1, 2014,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 PAR'T'IES:
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.
02O/ /oa70)
CWS-7A Individual Provider Contract I Revised 6/2014
01
4-1-e\
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.
S. 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 6/2014
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 .1 Revised 6/2014
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
inahility 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 62014
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.
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 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 shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement arc 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:
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
CWS-7A Individual Provider Contract 6 Revised 6/2014
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 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 6/2014
WHEREFORE„ the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
d, w 'County, on behalf of the Weld County Department
ATTEST: of Human Services
By: By: 2 -lut---
Deputy lerk to the Board Barbara Kirkmeyer, Chair HPR 1 3 2015
1,t'fL CONTRACTOR:
Approval as to Substa : n*
WELD COUNTY DE A ¢nd, Brad and Molly
OF HUMAN SERVI • ..,t1 t (-O,, 3l 25th Ave
4r•'� 'reeley, CO 80634
By: "L ( By; C--) ( /i-)Ol�7
unty Di ector's ( r design e's) Contractor' - or designee's) Signature
Si nature nd Dater ( and Date
By: ! r/��/
Contractor's (or designee's) Signature
and Date
H2O/S-/Odd 63)
C:WS-7A Individual Provider Contract 8 Revised 6/2014
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
APPROVED AS O F NDING:
Controller
APyf3�D� O F
Cou ttorney
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 Land,Brad and Molly, hereinafter referred to as, "Contractor."
GENERAL PROVISIONS
I. 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# 1543324. 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 hut 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 6/2014
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 he performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall he 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'
CWS-7A Individual Provider Contract 10 Revised 6/2014
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.
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 I I Revised 6/2014
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. 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.
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.
C'WS-7A Individual Provider Contract 12 Revised 6!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.
PI. I low 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 J
in the treatment plan? •
P2.How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions? f
P3. 1-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 C.
monitoring of 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?
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 sibling U
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:
gASgression/Cruelty to Animals Select One
Verbal or Physical Threatening Select One
O Destructive of Property/Fire Setting _ Select One
❑ Stealing Select One
R Self-injurious Behavior Select One
_ Substance Abuse Select One 1
Presence of Psychiatric Symptoms/Conditions Select One —
❑ . Enuresis/Encopresis Select One
❑ i Runaway Select One
O Sexual Offenses Select One
C Inappropriate Sexual Behavior Select One
-1711 Disruptive Behavior Select One
Delinquent Behavior Select One
C Depressive-like Behavior Select One —y
Medical Needs-(If condition is rated"severe",please Select One
complete the Medically fragile NBC)
I d Emancipation Select One
❑ Eating Problems I Select One 1
Boundary Issues Select One
1 Requires Night Care Select One
Education Select One
•
Cr ' Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
EXHIBIT C
Weld County Department or Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
rl r,,,,it'rt e K- ,7, rS t o- .. i"t. rJ ' �s 7 i m7�.� t P .,.'::::.-:;::." 2,'F......;
*�---1:,;',',:---..:-.-- -*","--
�A a 7y..„,-.46,0g4......4.0:4,"..-,.•Fi ,... . 7 i J ..;...--..,,,,*s—,
}�s ..a a-, -%7. .'.,•:.4':.,'4",--,.;. .,;_t'1.7.. J!R•!�JOfRiP S.�_63?�SGn•�:L�i3.. �'. +°�.. _ j
�r-+ �3 '�,�¢.�1 slrr 4r � . ,' L Z:.
F-1 $I2.14
County Basic • Age 0-10...$I6.73 _ $0.00 ;
5.66 No crisis intervention,Minimal
kiaintenance "1-v"R' Age I I-14...$18.5O RD CPA involvement,one face to = Not needed or cover
Rate Age 15-21...$19.75 - y as under Medicaid. i-,-
..,_44
,.
uas face visit with child per month. t2'.•!, -•A ;s,* S 15.51 55.05 t r
Minimal crisis intervention as r-•
t- Regularly Scheduled . ,
1 $20.22 t S'"
5 66 tip needed,one face-to-face visit .4 therapy up to 4 4 .
# I Y i per month with child.2-3
y hours/month a
— �" contacts per month
$23.59 r'�-. 5.66 $17.19 st
,, Occasional crisis intervention as `' Weekly scheduled
2 �y S26 90 needed, t therapy 5-8 hours a 5a.K9
two fact-to-face visits `00
5: with child,2-3 contacts per month with 4 hours i)f T
,. ,i
. ; - a month x group therapy.
2 'r: .--S.13 _ $.66 $20.56 ------- — 5"
''.a.
. .
$15.16 ,
4 52224
Regularly scheduled F
Ongoing cnsis intervention as weekly..multiple I'-"
Y° needed.weekly face-to-face ,,
3 S 3 7i; 5,6b ' sessions,can include $6.39
visits with child,and intensive �� more than I person,
coordination of multiple 1.e,family therapy,for
a= 1services.
r,= 1a 9-12 hours/monthly.
v. ; . _.r
,)(15 6 523.93 ` •
rt`Jii
r"a4
} $25.61 M -
"sue- ongoing crisis intervention as
4 .; . needed.which includes high , ,
R("("t•' 51O 41 g 6' - level of case management and a Negotiated
t
Drop Dunn CPA involvement with child and "
provider and 2-3 face-to face
c; contacts per week minimum.
i. x t
`.r :._Y "' J,.f J u .; ‘47..,i -Mg i° ..iA a "" .r F;:@I, : LP.=j
M. ''1. :
Assessment/ �y.
Emergency 7t... $26.96 5.66 $18.88 ^: .
-71
Level Rate 4 �',ttExhibit C to the Additional Provisions 14 Revised 6/2O14
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this /�1day of , 20/51
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 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 certificatellicense 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 1,2014, 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.
c20/.5-- /OO7O4O
CWS-7A Individual Provider Contract I Revised 1-112NC0%
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.
c. 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 6/2014
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 (H1PAA).
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 6/2014
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 6/2014
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.
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 he 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 he 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 shall he and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
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 6/2014
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 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 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 6i2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
(� (pia .L County, on behalf of the Weld County Department
ATTES . i �j G .JL�LO of I Iuman Services
/
BY: _ BY'
Deputy erk to thy-caard 2:2, arbara Kirkmeyer, Chair 1 3 Zt 5
f' 7t ONTRACTOR:
Approval as to Subst cc1'14 t
WELD COUNTY D h's91 `1', ( �derick. Douglas and Kelli
OF HUMAN SERVI ES } r Nil 1057th Ave
y�F,."a,. �°S,, Creel y� S X34
i .L i _,
o nty Dire tor's (or d ��� B
y:✓ y
y signce' Contractor s (or designe Signature
Sig attire an Date and fate
By. r —X_)1-i1/i,
till') ractor's (or designee's) Signature
and ate
C'WS-7A Individual Provider Contract 8 Revised 6/2014
02O/t /06760
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
OVED AS Fio F DINS
t_
Controller
APP O .
Coun orney
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 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# 10994. 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
he 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 he 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 shaft
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`t'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 6/2014
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 he 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 6/2014
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 I luman 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 6/2014
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 Vff and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
Emil BIT 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.
T1. How often are therai services needed to address child's individual needs ••r NBC assessment? r Select One
NBC (NEEDS BASED CARE ASSESSMENT)— Behavioral Assessment
Assessment Areas: Comment: Rating:
O Aggression/Cruelty to Animals Select One
I I 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
O Delinquent Behavior Select One
O Depressive-like Behavior Select One
! Medical Needs-(If condition is rated"severe",please Select One
O 1 complete the Medically fragile NBC)
O Emancipation Select One
❑ Eating Problems Select One
H Boundary Issues Select One
I 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
F:XH1BIT C
Weld County Department of Human Service
:Needs Based Care
Rate Table
(Effective 7/01/2014)
's;xr h q s r�afiC��" •' '4 t w'� ?2p4 _. Nr "A a _ • `{ sf y +ice• . "F rids
flit �y�W �t s ^`ry, T. y � S� �4a :. sl ie4'.'.l "). }r a
,PYD,` n r (h°tfsi �h }y� t-• i,; .l( ! �b t Z ins 4 > )�?3R '►��1^stad + � S4r�_1�3 t�
..,..,� s ^ sTA�"�4 . Yr 41s:' i '� �r�F,.i r '�i +�•P.�u 3i x. a.aat� ♦- t' '"♦u
j2 ' 1+ 1t x ^+ z !iJ5 {d{G1 A -(:.':,
y .t .,h. " Y ', ?t r T ♦.�...�i�+e k,l:its
g :t� P.lit ,t i'�." �` �f t.5 C �" J' i t, •s 1^'5 v4 ?1,4 r • ti
�� , 7 _ -+E tt a• ! F s '
1!.t Y st�W i' ` ' C iiyA � E i] ♦c w t 7 t !' tf h ld't+A t� "A �i�� 4.,
*may,., (♦,�+ .. �r >n, ti ,,+,•('� e '}'4- ''9ra-l.. t+� .. 's,�;•,
li
,r i�',' $12.14 zi.
County Basic rrrr{y Age 0-10...5I 6.73 '4.,:: 3.66 ; No crisis uuervention,Minimal '"x' $0.0U
•
Maintenance h^'.;: Age 11-14.318.50 t'' Not needed or cover .
CPA involvement,one face-to-
Rate k;-1' Age 15-21..519.75 under Medicaid. ,Y
face visit with child per month. u.{
�, , tb $15.51 :'.t
4,4 it.::
t t, - k Minimal crisis intervention as `�
1 $20.22 *Y" 5.66 Regularly Scheduled ..`i' 53.39
;.gin needed,one face-to-face visit therapy up •.:to 4
x.. ,' per month with child,2-3 !: hours/month. ,u
a t {
:' .arc 1.
contacts per month st.
.ir r
I ''A 523.59 ,, 5.66 t $17.19 f ----------
�4
:4' :' iiiii $18.88 '• •,
$10.11 ;z,
'9F., torts r
k: ii ;t:. Occasional crisis intervention as Weekly scheduled
2 S26.96 $.66 '.• needed,two face-to-face visits therapy 5 8 hours a '; $4,89
e month with 4 hours of ';.
,1 1+:4, with child,2-3 contacts per :
�` month group therapy. :d
2 A S3U,33 5.6b $20.56 •
.
1?.j'. :.{ 515.16 .,.•
:ii, +;;: $22.24 >` .
. Regularly scheduled 4
`'• Ongoing crisis intervention as ,. weekly,multiple
;s sw
3 'tr: needed,weekly face-to-face sessions,can include 56.39
1 visits with child,and intensive
e- .. more than I person,
coordination of multi k. "' r
4 Wit, multiple �x� it.family therapy,for
kh :z, services. xJ 9.12 hours/monthly. r
3 1/2 �,` S?7 it, 5.66 -:-R $23.93 cFP
,'Y'S ,44144
Ce 525.61 r
a;=, ;A Ongoing crisis intervention as +.
4 c-i needed,which includes high
RCCF , 540 41 S.t,G "` Negotiated
t,; Icvcl of case management and Mt
B
Drop Dow n 1c CPA involvement with child and '
t`',.. provider and 2-3 face-tn face .0...
,�"3+ contacts per week minimum '`,,*5,i `. P -1
� t,•< t.t rti h 4 +t F , -?,,w r ?rgf xi tga : *at'..t ittb
Assessment/ r ;
W.! ':.'il tr'' Ap
Emergency : 526,96 $.66 1 518.88
tig
Les el Rate ''" .
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this I day of } , 20/1-1
by and between the Board of County Commissioners of Weld County, on beh 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.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services(hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home(hereinafter referred to as"Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE. in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, 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.
2O/ =/O07O5)
CWS-7A Individual Provider Contract 1 Revised 6/2014
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.
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.
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 6/2014
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 6/2014
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 6/2014
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.
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.
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 shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
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.
Fl. 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 6'2014
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 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: / ;42 of I Iuman Services
By: BY: L
Deputy erktoth Barbara Kirkmpyer, Chair R 13 2015
et ONTRACTOR:
Approval as to Substa e: '442
WELD COUNTY DE uber, Nicole and Wright, Jon
OF HUMAN SERVICE, .0b kW 19 W. 22nd Street
,? 1 reeley, CO 80634
By: Jt �� By. *7/
C n y Direc or s(or signee' nt actor's(or designee's) Signature
Siign ture an Date and ate
By:
ntractor's(or d gnee's) Signal e
and Date
o2(9/, -.7O6 7(5)
CWS-7A Individual Provider Contract 8 Revised 6/2014
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
A�RO�S F NDING•
d4 coma,
Controller
AP OFD ? .
f �:.
Cou attorney
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 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# 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 9 Revised 6/2014
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 fonn 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 he 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 6/2014
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.
I I. 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 1 I Revised 6/2014
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 6/2014
F,XHIKIT 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. I low 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 h1the provider in scheduling Select One
and
monitoring of 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?
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:
H 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
'. Select One
_ Sexual Offeatses
Inappropriate Sexual Behavior Select One
Disruptive Behavior Select One
Delinquent Behavior Select One
l 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 I Select One
O Boundary Issues Select One
I O 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
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
p w.. .. y4., a+�.."a•-fir.`
y'-., nG Y r �q' „.a�M 7 •`c r u's .'• "-,�5x'' T�'q+�-:ai Yi, •^ {.r r Kv-ttat,+`�T .t1, "`T 5�
'*" ti,xe1111.#2,41:
,. ,r. �.-.,r,t.x.--:, �,►-�r x '''')--ii 9 c g.:•' ',..--;,•,-y l• :-,-.;•:44 �_,t t: 1,
. t . i .7.; L'tr� 1e, 1-Y,41: Fro �P474, A;,t iF• Y!. .I �5,i r e5Kh •`st.,. ei g.'; . R; Y
,,r a` ,:t
a -Fist,n7.. "y jAv ',F.3 'q p i *; 1'-1 a j, ;.,-,..t.-4`.3-9'.1-1*-...„.,�,� 11.�..ty. •T r,s.. a:: r t t.4.,? t�
,�� "Y . �. r .,r.-, , t..F'`#a.. ,,.„,:-._..',ir^ f, , Y„ t 4 — µr } n
-Air "' r,41", a t ,4r tt ,;� 'p.4 1; c. ,.,{- r V ..a�JRC
:...11r� z5. .d af' kPY4MF �C4S�e .d1's( ...t
-- ,r+s r. a . ..1,f ,s t,04 .�-a rr .f /., 'z'- , -,�,"rtr ,4g 5�Y. i , .
at
County Basic Age 0-10...S16.73 $12.1 • $0.00
,, S.66 ' ,r No crisis intervention.Minimal .
�larntenance •': Agc I1-E4...S18.50 3 Not needed or cover
t CPA involvement.one face-to- under Medicaid.
Rate Age IS-?I..-$19.75 -:•.•-j' •,:,. ' }'ace visit with child per month. •I'• . ,a. — —
p $15.51 $5.05
a
Minimal crisis inlcrvcntinn as
5 Regularly Scheduled ham- S
1 S..` ' S.6F :k needed,one face-to-face visit therapy up to 4
K. p
i per month with child,2-3 hours/month.
ll �:, contacts per month .. t __
— — :wTM yes
♦.'. t�-
1 :; • S.21 5g ..-. 5.66 ' $17.19 -----------
- — _ 510.11
_ $18.88
' Occasional crisis intervention as Weekly scheduled
2 S,r,•,F, _ x 'C 66 needed,two face-to-face visits therapy 5-8 hours a $d.k4
'' '-" •
with child,2.3 contacts per month with 4 hours Ut
month group therapy.
z` $30 3 ` 566 $20,56 r. ---- --
y; r
— — vi $15.16
a_ -, 1 $22.24
-
a`' Regularly scheduled „n
.1 r Ongoing crisis intervention as weekly,multiple x'
- needed,weekly face-to-face ,. .
3 S-,1. 0 S 66 , , session.,can include Sfi.?9
visits with child,and intensive mote than I person. 'g44
ti , i� coordination of multiple i.e.family therapy,for `
services. 9.12 hours1monthly.
'ikirt
3 1/2 $37 06 5,66 $23.93itil
' $25.61 ,t
• gti k� r
MS
�: ,;v. Ongoing crisis intervention as ,
4 s - needed,which includes high .
RCCI, 5-10.44 t" 5.66 level of case management and 'JL�`''i'ted
Drop Down " CPA involvement with child and .r
PI
;r x s provider and 2.3 face-to face
pit
#tOp urr dcis(per%seek minimum tfig. jj3}�y }
p, :A'!�-a off. }-.,�-. '.-y _.._r1 r''-.r �:'.. t 3 ri a- 3YY.- .1r.' >' ?�^1 40, :L"... s.. ..Vitt. w..:-' ....•�..•( l
Assessment/
Emergency , $?6.96 S.66 ,� 518.88
-; N
r.,,,,,
Lesel Rail: - -` 6,1
Revised 6/2014
Exhibit C to the Additional Provisions i4
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGRE1 MENT
THIS AGREEMENT is made and entered into this 0__day of L— ,2016 ,
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." 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 Ilome(hereinafter referred to as"Facility"),and
WHEREAS,Contractor understands and agrees that it must,during the term hereof,hold
a valid certificate/license for the Facility,maintain certification standards,and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department,and
WHEREAS,County may,but shall not be obligated to, purchase foster care services,and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW,THEREFORE, in consideration of the mutual promises and covenants made
herein,County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014, to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
13. 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.
S-7A Individual Provider Contract 1 Revised 6/2014
02x /3— /007(/6
oRcogu
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.
C\vs-7A individual Provider Contract 2 Revised 6/2014
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 6/2014
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-rA Individual Provider Contract 4 Revised 6/2014
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 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 shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
C.'WS-7A Individual Provider Contract 5 Revised 6/2014
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:
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
C\VS-7A Individual f'rovider Contract 6 Revised 6/2014
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 he defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but arc 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 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.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above,
COUNTY:
The Board of County Commissioners of Weld
dd�+� !` %� County, on behalf of the Weld County Department
ATTEST: �` of Human Services
By: ii -'- , % By ( Abe-1—i_______`-'
Deputy 9 rk tv�. Barbara Kirkmeyer, Chair
APR 132415
tu 4,41$7,„e:4,7,„4 CONTRACTOR:
Approval as to Subs -%
WELD COUNTY • 'r: Walker, Kurt and Jennifer
OF HUMAN 1519 Trout Creek Ct
=-rY 7 k;i ,�,/,' Windsor, CO 80550-3194
By: i 1 Aft By: Co u P !OH lip
Co n y irect r (or p ignee' Coi} actor's r designee's) Signature
Sin ure and ate and Date
../ By: �� ,v a0r,6/�ji(-/'
Contractor's(or designee's)Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
o2oi5- ioo 7 06)
APPROVED AS TO SUBSTANCE:
SEE PREVIOUS PAGE
Elected Official or Department Head
N/A
Director of General Services
7+0.
Controller
AP OF' ' ' :
Cou Attorney
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
I. 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#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 9 Revised 6/2014
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 I-luman
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify I Iuman 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 6/2014
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 1 Iuman 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. Arc 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 6/2014
•
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.
]3. 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 6/2014
$XHIBIT 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
approoriate 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.
Tl.How often are thera.v services needed to address child's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT)—Behavioral Assessment
Assessment Areas: Comment: Jiatln
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 I _ Select One
Presence of Psychiatric Symptoms/Conditions —� Select One
Enuresis/=ncopresis 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 -
-n 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)
C Y . :3�! F -v; , Y 1 to
ifs r.+�i y,�$r �' �, M� t -a r 1 -c, `� 9 ?-, r '"
a d:':-.1-,....;- 'F,.n ' `t .ti aF'i. �7.T. s �`' i 't rrr ��y spr µ$-a Fl...?-4',.-n-'7,,,
rk St v k 4 `.A -Oi i, 4 - 5 a
'513a3 i `3` finv�:'e s r4Y�'!Sl t yhS Jrtt� .x• C -e�,�". M�
�.,,,. , 4 To�} is .:kt _ fir,.7�. ci. 7..4'..4-- 5'.. R , ..q' .1.7:4TV•M•.'7-!c ' (t..41' �y.: 'l�'4lE l�r.-?�;M.r. .,+ ' -
4•
512.14 ;;v r.1.County Basic t Age 0-10...516.73 . $0.00
5.66 : No crisis intervention,Minimal ,1;. n'^
Maintenance Age 11-14...$18.50 t' ;4.0 Not needed or cover f
g CPA involvement,one face-to- i '
Rate Age 15-21...$19.75 under Medicaid. F-.,
x• +• face visit with child per month. K, •
515,51 $5.05 af
Minimal crisis intervention as
r,. Regularly Scheduled
1 $20.22 _'' $.66 needed,one face-to-face visit - "" 53.34
.=_;: ,k therapy up to 4 a::
;�, per month with child,2-3 hours/month.
";; t; ' contacts per month } V4
1 '% 91 S23.59 ,..6..r.
a< 566 $17.19
k"'
$18.88 1•.-, 510.11 ax-.,
r. Occasional crisis intervention as Weekly scheduled +';
2 $26.96 S•66 needed,two face-to-face visits therapy 5-8 hours a $4 t9
s. with child,2-3 contacts per sid,�,� month with 4 hours of
x month ' group therapy. ' �
2% ' • 530.33 $.66 1 520.56 ----------- iii'
$
515.16
22.24 ^'
_ 3f Regularly scheduled
.;cif Ongoing crisis intervention as weekly,multiple
i' needed,weekly face-to-face
3 "i;,t. $33.70 $.66 r.;; sessions,can include 56.x'9
r -:' visits with child,and intensive more than I person, s RY
o
''%'' coordination of multiple416,
=''.
�'
44t i.e.family therapy,fur
1 services. x.1'1 9-12 hours/monthly. 4
31/2 el, $37.06 5.66 ZiFii $23.93
°rz
.9y: 525.61
Ongoing crisis intervention as
4 'k needed,which includes high
RCCF ea $40.44 �•, S-66 level of case management and i , Negotiated
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;�i � S { y CPA involvement with child and
%e}:= ° provider and 2-3 face-to face
it4 contacts per week minimums,j"4 x "'! 'y ip eu4 v`-- x, • .1 IN r3N:4Aa Ca 'mot S Y<,. g-:"eMt '40fdtt f t} t
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Assessment! ' + #
Emergency $26.96 5.66 $18.88 �4' .....
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Level Rate t '{ '
r S ilk, �k`++ 1
Exhibit C to the Additional Provisions 14 Revised 6/2014
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