HomeMy WebLinkAbout20143916.tiff MEMORANDUM
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DATE: December 11 , 2014
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' TO: Douglas Rademacher, Chair Boyd of/co Commissioners
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- CQ U-N T i•� FROM: Judy A. Griego, Director, maniervrces part ent
RE: Individual Provider Contracts for Purpose 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
October 30, 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 Guilbert, Jeanine & Jonathan Foster Home $0
July 1 , 2014 — June 30, 2015 Kingwood, Texas
2 Kliewer, Pamela & Christopher Foster Home $ 16.73 - $40.44
August 11 , 2014 - June 30, 2015 Firestone, Colorado
3 Martinez, Stacey & Jeremy Foster Home $ 16.73 - $40.44
July 14, 2014 — June 30, 2015 Erie, Colorado
4 Rosenoff, Kelsey & JayDee Foster Home $ 16.73 - $40.44
August 5 , 2014 - June 30, 2015 Windsor, Colorado
5 Rousch, Rebecca & Branden Foster Home $ 16.73 - $40.44
July 1 , 2014 — June 30, 2015 Kersey, Colorado
6 Sommerfield, Angela & Robert Foster Home $ 16.73 - $40.44
September 2, 2014 Greeley, Colorado
7 Stone, Mary & Jamie Foster Home $ 16.73 - $40.44
August 18, 2014 - June 30, 2015 Greeley, Colorado
8 Vargas, Jolene & Jose Foster Home $0
August 22, 2014 — June 30, 2015 Johnstown, Colorado
If you have questions, please give me a call at extension 6510.
RECEIVED
de : I-/SD (Sµ) DEC 1 1 Kik
/oZ7 7/i71 WELD COUNTY
Ji
A COMMISSIONERS
±COWIl m 2014-3916
19)11'14
11 .O
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEI 1ENT
THIS AGREEMENT is made and entered into this/I day of T 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 Guilbert,Jeanine and Jonathan,whose address is
2131 Fir Spring Drive,Kingwood,TX 77339, hereinafter referred to as, "Contractor." This
Agreement covers all children placed by County with Contractor.
WITNESSETH:
SETH:
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.
CWS-7A Individual Provider Contract 1 Revised 6/2014
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
2. To safely provide the 24-hour physical care and supervision of each child until
removed or until the agreement is renewed.
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.
G. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the
Department.
10. To allow representatives of the County Department to visit the foster home and to
see the child at any reasonable time.
1 1. 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.
CWS-7A Individual Provider Contract 2 Revised 6/2014
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
F. Any conflict the child may have with law enforcement, school officials, or
other persons in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or
supervising agency.
i. Any information received regarding a change of address of the parents or
guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of
1973, and the ADA of 1990, concerning discrimination on the basis of race, color,
sex, age, religion, political beliefs, national origin, or handicap, and to provide
confidentiality of information concerning the child in compliance with the Health
Insurance Portability and Accountability Act(HEPAA).
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Coster 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
CWS-7A Individual Provider Contract 3 Revised 6/2014
laws and regulations, as such, which may be amended from time to time,and shall
be binding on Contractor and control any disputes in this Agreement.
23.To maintain a current license and maintain license requirements as specified
under State law and rule.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times during the term of this Agreement a liability insurance
policy of at least$25,000 for property damage liability, $150,000 for injury
and/or damage to any one person, and $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
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, p arental,
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.
CWS-7A Individual Provider Contract 4 Revised 6/2014
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility.The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency.An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
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.
CWS-7A Individual Provider Contract 5 Revised 6/2014
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
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.
CWS-7A individual Provider Contract 6 Revised 6/2014
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. 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.
CWS-7A Individual Provider Contract 7 Revised 6/2014
N. In addition to terminating this Agreement, in accordance with the provisions of
Section 1., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope of
work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include, but
are not limited to,any one or more of the following:
1. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement,or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
0. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge
and agree that no part of this Agreement is intended to circumvent or replace such
immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five(5)calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 8 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
1 County, on behalf of the Weld County Department
ATTEST: ^d����6: ,,.... ,,. .!,17.,_
�' ` ' of Human Services
Deputy C rk to the Board4* (.-- emac er, Chairman
DEC 1 7 Z014
CONTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT Guilbert,Jeanine and Jonathan
OF HUMAN SERVICES 2131 Fir Spring Drive
Kingwood,TX 77339
Hy:(-Ichttiku- D'ki\, utligs. ;ii)g-il'-{
my Di ector's o design s) Cc tractor's(or designee's) Signature
i ature d Date . and Date By: ?/I/I$i` C
ctor's or esignee's)Signature
and Date
CWS-7A Individual Provider Contract 9 Revised 6/2014
I
as/ I- ,39/
APPROVED AS TO SUBSTANCE:
SEE ?Rev'eus"he F
Elected Official or Department Head
n1 IA
Director of General Services
APPROVED AS TO FUNDING:
ajz„.d X71
Controller
APPROVED AS TO FORM:
County Attorney
0213/V- <39/6.
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
fil
THIS AGREEMENT is made and entered into this / 7 day of e3 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 Kliewer, Pamela and Christopher, whose address is
10473 Taylor Avenue, Firestone, CO 80504, hereinafter referred to as, "Contractor." This
Agreement covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the 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 August 11, 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 I 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.
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. hi 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.
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 fiirther, 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.
or deliverables which
for those services
ment or recover reimbursement
2. Denypay
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 IERIFORE, 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: � ►. . 1�to%e.C of Human Services
B�v / • l.«--+. BY; •
Deputy lerlc t' t i lac "d '.? " `` _r` Dot(ilas Itadefnachcr, Chairman
CONTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT Kliewer, Pamela and Christopher
OF HUMAN SERVICES 10473 Taylor Avenue
Firestone, CO 80504
By: By: t , , � _ ) .�,� �• Q13L11/2014
C u ity Di ector's ( r desi tee's) Contractor's(or desig,nce's) Signature
igt aturc •nd Date; and Date ,•
By: 08/11/2014
Contractor's (or designee's) Signature
and Date
t7 l0Z/i- l 180
til-0Z/t l-/80
•
('WS-7A Individual Provider Contract 8 Revised 6/2014
a4 /'/ 3 9/(
APPROVED AS TO SUBSTANCE:
SEC PPEvious PAAF'
Elected Official Department Head
c or
N /A
Director of General Services
APPROVED AS TO UNDIN/G,:
;Vic Itati
Controller
APPROV�O FORM:
County Attorney
��� 89/
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 Kliewer, Pamela and Christopher, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit 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# 1587944. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writinu 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°i 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 VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
1
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 thcprovider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding, bathing. grooming,physical,and/or occupational therapy?
Al. How often is CPA/County case management required? (Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
TI. How often are thera services needed to address child's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cruelty to Animals Select One
❑ Verbal or Physical Threatening Select One
❑ Destructive of Property/Fire Setting Select One
❑ Stealing Select One
❑ Self-injurious Behavior 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
❑
complete the Medically fragile NBC)
O Emancipation Select One
❑ Eating Problems Select One
❑ Boundary Issues Select One
❑ Requires Night Care Select One
❑ Education Select One
U 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 NEEDS
A..
Level DailyRate Dail} aIe Daily Rate ..:t'...::':''''1:;
. p r., Dail-Rate =,!;{ Daily Rate
:45; S12.14
50.00
Count'Basic . -F: ,. Age 0-10...$16.73 a
,, $.66 No crisis intervention,Minimal Not needed or cover 1.1
Maintenance Age 11-14...$18.50 CPA involvement,one face-to-
Rate Age 15-21...$19.75 under Medicaid.
face visit with child per month.
$15.51• $5.05
Minimal crisis intervention as Regularly Scheduled
1 $20.22 S.66 needed,one face-to-face visit thera a to 4 $3.39
Py P
• per month with child,2-3 it
hours-month. .
contacts per month }
.....-
1 ',4 52359 $.66 S17.19 .• --
S18.88 S10.11
Occasional crisis intervention as Weekly scheduled
2 $26.96 $.66 needed,two face-to-face visits therapy 5-8 hours a $4.89
has with child,2-3 contacts per month with 4 hours of
i month group therapy.
2 '' $30.33 5.66 S20.56 --------
S22.24 f;, S15.16
:_'t Regularly scheduled
Ongoing crisis intervention as weekly,multiple
needed,weekly face-to-face
3 $33.70 S.6G 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 hours/monthly.
31/2 $37.06 $.66 $23.93 ---- --------
.
. — —
S2 5.61
Ongoing crisis intervention as
4 needed,which includes high
RCCF S4044 $.66 level of case management and Negotiated
i Drop Down CPA involvement with child and
provider and 2-3 face-to face
contacts per week minimum.
. Assessment/
Emergency $26.96 S 66 SI8.88
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/7lay of Teat8 20/�,
by and between the Board of County Commissioners of Weld County,on behalf of the Weld
County Department of I luman Services,whose address is P.O. Box A,Greeley, CO, 80632,
hereinafter referred to as,"County,"and Martinez,Stacey and Jeremy, whose address is 1149
Northview Dr, Erie,CO 80516, hereinafter referred to as, "Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSFi'FI:
WI IEREAS, 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 14,2014,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 tester 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 t 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 ill the development of the Family Service Plans for children in
placement, including visits with their parents, siblings, and relatives,or transition
to another luster 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 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 6f201-4
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(111PAA).
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.
I9. 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 he by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2.014
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 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 Fxhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition,deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not he construed as prohibiting the periodic amending
of this Agreement. Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services 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 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.
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.
.1. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies. procedures. and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. 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:
1. Are not presently debarred, suspended. proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not. within a three-year period of preceding this Agreement. been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining,attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of'embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (13)above.
4. Have not within a three-year period preceding this Agreement. had one or more
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:
•
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 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 enlorcement 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'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
V - " � , County, on behalf of the Weld County Department
ATTEST: - }',, of Human Services
By. I By n,y (g. ... 1-szy,1o.--kA:q - —
Deput) Jerk tcistfteli$rd:: - Doutlas Raden acher, Chairman
DEC 1i2014
CONTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT Martinez, Stacey and Jeremy
OF HUMAN SERVICES 1 149 Northview Dr
Erie,CO 80516
By: . . Lit-G )'.. -' r'1 ) By:�C: \ t X. 14/2014
CQ my Dijector's.& r desiiiiee's) Contractoror designee's) Signature
Sig ature and Date' and D
By: ./. 7/14/2014
C ctor's(or designee's) Signature
and Date
020/4 -39/4-
CWS-7A individual Provider Contract 8 Revised 6/2014
APPROVED AS TO SUBSTANCE:
See- PREVIOaS ?AGE-
Elected Official or Department Head
MM
Director of General Services
APPROVED AS TO FUNDING:
,L1/0 a/41_
Controller
APPROVE FORM:
County Attorney
a0/V- 39/&
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
S-7A
The following additional provisions apply to the agreement entitled, "individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement,"hereinafter
referred to as, "County."and Martinez, Stacey and Jeremy, hereinafter referred to as.
"Contractor."
GENERAL, PROVISIONS
I. County and Contractor agree that a child specific Needs Based Care Assessment.
designated within this exhibit as Exhibit E3, 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
fosterladoption 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
arc 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# 1649838. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
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
writin by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in \‘riting may be denied.
All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided,the County reserves the right to
deny payment.
B. Be submitted by the 4`1 of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25) calendar days of
the month following service, it may result in forfeiture of payment.
• C\!S-7A lndividua: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
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
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:
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.
� if consideringgiving notice to remove a child, except in emergen
cy
... Request a staffing
qf�
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 firth in Section 19-3-304, C.K.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 he accessed through F1i:X)S.
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. I lave not_ within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
C'WS-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 I luman
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. I low(Alen is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. l 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('PA/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. }iow often are thera N services needed to address child's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
^
Assessment Areas: Comment: Ratln9:
O Aggression'Cruel() to Animals Select One ,
, O Verbal or Physical Threatening _Select One
❑ Destructive of Property/Fire Setting Select One
❑ Stealing Select One
O Self-incurious Behavior Select One
Select One
❑ Substance Abuse
❑ Presence of Psychiatric Symptoms/Conditions Select One
❑ Enuresislncopresis _ __ Select One
a Runaway Select One
❑ Sexual Offenses _ Select One
RInappropriate 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
EBoundary Issues Select One
Requires Night Care Select One
❑ Education Select One
O Involvement with Child's Family Select One
Exhibit B to the Additional Provisions I3 Revised 6/20 14
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
4 •1:4N:1;44,*--'-til,.'
r ,.r .Y".. t f , , m
te
• xti.../../..,.1...td f'p .4t `s t ^` f - fi n,. z, lh �tii 2 t'').70 It.f.
+l•4 �1 L:.... iv`, u,I.�-�.�..aoa.0 atrf. �' ..,1 ... :-.-,":.:,,,,L.,,;:-,. 4 ' 'i txn4� —I-.*':1�I y�K- 7p _.A 9
. 7. ^�iaw 4p` ,. ' v n If.flz: t: -t;�Hl!"SI t, �.,- 9 x ' _�'"1`•"' 1 ' ,S' 4;`-.
..1,-,..-", ,• -K•,I,dh" �l et rr. -Jr�g
, ,, 14 J \
County Basic Z Age 0-10...$16.73 „q: - $0.00 '
, - 66 si cryention Minimal ,{
S No en.is mt
Maintenance � y Nut needed or cover
y Age 1 I-14...518.50 ;. CPA insolvement,one face-to- ',
Kate ' Age 15-2I...S19.73 ry "''I under Medicaid.
- face visit with child per month
$15.51 -t:'-.
••i•-••• 4
t F: 30,, 55.05
" iliMinimal crisis intervention as •
IRS. $?fit S.6G Regularly Scheduled F; $3,39
needed,one face-to-face visit therapy up to 3 C�tir
. •,�M per month ssith child.2-3 .� hours`munth.
' contacts per month
0.g $17.19
stL
5,
' SI8.88 $10.11? ti
'T..' - Occasional crisis intervention a, ��'rekiy scheduled
2 S 21,9,, 5.66 sr needed,two face-to-face visits therapy 5.8 hours a $4.89
•
with child.2-3 contacts per ttts)nth ssith 4 hours of
etb
month group therapy.
Pt
2 ;5 S30.3 3 $.66 $20.56
a+ vrl a.
$22.24 $15.16
ix Regularly scheduled
Ongoing crisis intervention as . Keekly.multiple
needed.weekly face-to-face
3 S'"—..) 5.66 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.`monthl t'" _
r
31'2 S u,, r S 6 $23.93
1":%. ..
—— _ --., 1
.4:—.• $25.61
`;
, Ongoing crisis Miencntion as ,
4 -- r, needed.which includes high
R('( I 5-ln 44 .' S.66 level ofease management and Negotiated
I)ri,p Dim n 4 CPA involvement with child and { .`-:
provider and 2-3 face-to face
.a
.:: ygg p contacts per week minimum.
n� f, xrh �xt �$ xih�- xU1Y±'tW' �2. ,`t
�ti.
,ssessmcnt/
s
Emergency ' S?t,,>+ 5.66 518.88
•
Level Rate
Exhibit('to the Additional Provisions 14 Revised 612014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT ,,//__
THIS AGREEMENT is made and entered into this /11day of 0 /`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 Rosenoff,Kelsey and JayDee, whose address is 591
Dakota Court, Windsor, CO 80550, hereinafter referred to as, "Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS,the 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 August 5,2014,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.
9/6_
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 ofthe 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 E luman
Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money fromparents or guardians.
p o ey
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.
C. 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.
I7. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family
Homes or Specialized Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal
personnel. The records shall document the type of care and the term during which
care is provided for each child. In addition, medical, educational, and progress
summary records shall be maintained for each child in accordance with Volume 7
requirements.
21. To maintain medical, dental and educational records for each child/youth and
supply updated information to the County Department.
22. To conform with and abide by all rules and regulations of the Colorado
Department of 1-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
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 ofat 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.
13. County agrees:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
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:
HI. 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 ofthis Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
1. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. 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 tbund 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.
0. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention ofthe
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 alter 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:
� ir� if '..
The Board of County Commissioners of Weld
'r• �.:s; :%` County, on behalf of the Weld County Department
ATTEST:�� • of Human Services.:(. . .tb...t, 9 r-
P 7 `� -
B
Deputy lerk to the o`4r} w;-,.'._ Dou as Radema er, Chairman ., 7.Cpl?
CONTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT Rosenoft; Kelsey and JayDee
OF HUMAN SERVICES 591 Dakota Court
Windsor, CO 80550
By: ' „‘ r By: :aV 08/05/2014
ty Dir tor's 4r desi ' ee's) n ctor's (or design 's) Signature
g ture d Date and Date
By: 8/05/2014
Contracto s (or designee' ignature
and Dat
t
as i ,3 9‘/
CWS-7A Individual Provider Contract 8 Revised 6/2014
APPROVED AS TO SUBSTANCE:
SEE- PetItouts p46E
Elected Official or Department Head
iitr
Director of General Services
APPROVED AS TO UNDING:
----Tau-42,14 O17j/11
Controller
APPRO�O FORM:
County Attorney
1�- 39/6-
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Rosenoff, Kelsey and Jaydee, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit 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# 1652955. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments 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. 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,
compla
int, or other h r 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.
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
F'\1I IRIT 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.
[l. 1 low 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 ace Select One
appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy?
Al.How often is CPA/County case management required?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
T1. How often are theca. services needed to address child's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cruelty to Animals Select One
❑ Verbal or Physical Threatening - Select One
❑ Destructive of Property/Fire Setting Select One
Li Stealing _ Select One
J Self-injurious Behavior Select One
❑ Substance Abuse Select One
El Presence of Psychiatric Symptoms/Conditions Select One
' ❑_ Enuresis/Encopresis Select One
1:3Runaway Select One
Sexual OfTenses _ Select One
❑ Inappropriate Sexual BehaviorSelect 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)
U Emancipation 1 Select One
❑ TEating Problems 'Select One
Er 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)
� r'a' Sl'�?o.0 - � s"? . 4 17Y 4
1 FVIuI '' " A } t f+ 1 ^HIV ,, k ' ►D - ` ,
� r
yy����f G �• '�q 1. , . ,tl�'."�i ,v i.P� ♦ ? V raE
Z1.+NU' ( M ]�, A, l, 1 S.:..�a L.�+.. f 'Y' '.�� 1./ 4. dcc,
i i
z sP.^^�`+,,9 i1S, s ' ,i4.4r„ .p}.: r ff nr i r 1?'� t�� 11 }` r'
X14 ._L " .,�rDatl�r ,, a at ,Ie: 4 • +�D y �;�. J�,� �� - �,tfDatl� • {�v� <ir.�
...".".;.-.%7;•:;-',7- 01.1:3 :3 } i', - +..4n ,t ; .`'. x _1 i,.k'i...J'`:'�: r1a,•%`'it' 'k..4_ .�srigl',.;•:• +ts
;; *
$12.14
County Basic Age 0-10...$16.73 ;r`. $0.00
. $.66 No crisis intervention,Minimal t
Maintenance Age 11-14...$18.50 • s;: ;' Not needed or cover
CPA involvement,one face-to-
Rate. Age 15-21...$19.75 `'rl under Medicaid. I
r face visit with child per month. A,
$15.51 $5.05
iMinimal crisis intervention as 2 Regularly Scheduled tlii
1 520.22 - $.66 x- necdcd,one face-to-face visit • therapy up to 4 $3.39
pp. per month with child,2-3 hours/month.
_.k
contacts per month ''
7.. t
$17.19 a
P
$18.88 $10.11 io
' Occasional crisis intervention as V" Weekly scheduled
it-P2 S2 .96 $.66 necdcd,two face-to-face visitsF'.4 therapy 5-8 hours a $4.89
} t;g with child,2-3 contacts per '6 - month with 4 hours of
monthF group therapy.
2 Y: S30 33 $,66 $20.56 ;,.s ---------- --------
+i:-raj
•$22.24 f�� $15.16
`kr.
Regularly scheduled
,��
Ongoing crisis intervention as weekly,multiple •1
$ 70 needed,week) face-to-face
3 $.66 y :Y sessions,can include ^ $6.39
: visits with child,and intensive iffet more than l person, r'
coordination of multiple 1` i.e. family therapy,for
t•: services. 9-12 hours/monthly. i3 1'2 S3'06 5.66 $23.93 y — ---------
r
• $25.61
Ongoing crisis intervention as '
3x;.1
needed,which includes high . ' "
RCt:F s40,,,1 S GG ----- Negotiated
level of case management and � -"--- '
Drop Doan CPA involvement with child and ₹..'•`
• provider and 2-3 face-to face c
contacts per week minimum. '.+'
: Assessment/ - "`
Acci
i Emergency jar "1 ;r, $18.88 : tq
Level Rate .'
At
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
7r �
THIS AGREEMENT is made and entered into this , day of PeGc s20I
by and between the Board of County Commissioners of Weld County, on behalf of the Weld
County Department of I luman Services, whose address is P.O. Box A, Greeley. CO, 80632.
hereinafter referred to as, "County," and Roush, Rebecca and Branden,whose address is P.O.
Box 223, Kersey,CO 80644, hereinafter referred to as, "Contractor." This Agreement covers
all children placed by County with Contractor.
W FI N I:SSE:TI I:
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 he fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WI IEREAS. County may. but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any dine within the limits of the Facility's certificate/license and without prior notice.
• NOW, THEREFORE, in consideration ol'thc 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:
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.
„52 //- '39/6'
('WS-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 ofthe Family Service Plans for children in
placement, including visits with their parents, siblings, and relatives, or transition
to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human
Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the
Department.
10. To allow representatives of the County Department to visit the foster home and to
see the child at any reasonable time.
II. To give the County Department two weeks notice, except in an emergency, to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. An. 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.
('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(Ii1PAA).
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 arc necessary fi'r 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
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 tees 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.
C'W'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:
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 ot'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 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 tester homes. The county
department is responsible for providing information on county specific
procedures.
f. 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.
lll. GENERAL. PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall he deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent. employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado. county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado. county, and federal funds for the purpose thereof.
C. It is agreed that if. after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children. Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to 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 ally force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal. addition. deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not he construed as prohibiting the periodic amending
of this Agreement. Exhibit A and the Needs Based Care Addendum in writing. if
agreed to by both parties. This Agreement. Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
i . 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\VS-7A Individual Provider Contract 5 Revised 6`2014
the purchase of services in this Agreement are carried out 1or 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 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.
E I. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement. where
such failure is due to any cause beyond its reasonable control. including but not
limited to Acts of God, fires, strikes, war. flood, earthquakes or Governmental actions.
1. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies. procedures. and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. 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. I lave not. within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement.
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal. state,or local) with commission of any of the offenses
enumerated in paragraph (B)above.
4. Have not within a three-year period preceding this Agreement, had one or more
('WS-7A Individual Provider Contract G 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:
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 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 entorcement of the terms and conditions
of this Agreement. and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of'action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement he deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor. within five (5)calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
('W'S-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 Corn m issioners of Weld
��"'"� 1 . County.on behalf of the Weld County Department
ATTEST: �'4a" }"; ::1" ,,.�` of Human Services
By. ��..By OL.9(Rte
[)�huty ' -rk t tl 'a '= . )ough�ls adema er,Chairman
..� DEC 1 7
2014
-. ,
CONTRACTOR:
Approval as to Substance:
WELL)CO(.1N-I'Y DEPARTMENT Roush, Rebecca and Branden
of I IUMAN SERVICES P.O. Box 223
Kersey, CO 80644
By: By:
C ty Dire tor's (u design 's) Co ractor's(or ignee's) Signature
' gt ture an Date and Date
By:
_C ntractor's(or designee's) Signature
and Date
o2. (-5/
CWS-7A Individual Provider Contract 8 Revised 672014
APPROVED AS TO SUBSTANCE:
SEE- PECvious PAGE'
Elected Official or Department Head
N/A
Director of General Services
APPROVED AS TO FUNDING:
Controller
APPROVED AS TO FORM:
County Attorney
02,o/$ 39/6
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 Roush, Rebecca and Branden. 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# 1652189. 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 tor 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
\tiriting by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may he denied.
�. 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.
13. Be submitted by the 4'h of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25) calendar days of
the month following service, it may result in forfeiture of payment.
('WS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall be paid from the date of placement up to,
hut not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
F. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (LIDOS).
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 he deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses. nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
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;
13. 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 I luman Services and the Contractor, or by Human
Services as a debt to I luman 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 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:
1. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
_'. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
C'ontractor'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 hinder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis. it-child is taking medications.
V 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. 1 lave not, within a three-year period of preceding this Agreement. been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain. or performing
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.
1 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 I2 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
l'herapy: 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 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. 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
i 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 8er 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
❑ Stealint; Select One
❑ Self-injurious Behavior _Select One
❑ Substance Abuse Select One ,
El _Presence of Psychiatric Symptoms'Conditions Select One
❑ Enuresis.'Encopresis Select One
Runaway Select One
Q 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
0 __ Boundary Issues Select One
D Requires Night Care Select One
❑ Education Select One
❑ involvement with Child's Family Select One
Exhibit l3 to the Additional Provisions 13 Revised 6./2014
EXHIBIT C
Weld County Department of human Service
Needs Based Care
Rate Table
(Effective 7/01 Sr1 ./2014)
. .yt ,_ F .S.. {Fib^ ' Y C Y . :.
LEVEL OF CHILD RESPITE' AD1k.1- t 5s ADMINTS`I'RATWE - hfE• DIC4L
SERVICE MAINTENANCE . M • , • EDS SERYIC
Level Daily.Rate Daily Rate!.. " ' Daily'Rate - Daily Rgte _ Daily'Rate
512.14
Count% Basic Age 0-10...$16.73 :' $0.00
ht, No crisis intervention.Minimal
5laintenance Age I I-14...$IK.50 Not needed or cover
CIA imohcment,one face-to-
Rate Age 15-21...$19.75 • glee isit with child per month. under Medicaid,
$15.51 55,05
Minimal crisis intervention as Regularly Scheduled
I - $20.22 ti(,!, needed,one face-to-face visit %„; ',,
therapy up to 4
per month with child.2.3 hours•month.
contacts per month
I 'A $23.59 S r,r, $17.19 "`
$IR.Rx $10.11
Uccasional crisis intervention as .5.?;.:' U'cekh scheduled
2 $26.96 S r,c, :f} therapy 5-K hours a c,4 ',,
n�wded,two titre-to-tare visits .j P
with child.2-3 contacts per s•. month with 4 hours of
_ month group therapy.
.• c...,,,.,) -:: c„e)6 $20.56 r, .
c$
' —
$22.24 ;71'5.1";
$15.16
;r Regularly scheduled
Ongoing crisis intervention as ;`; weekly,multiple
needed.vycckly face-to-face '="t
3 $33.7(1 S.66, se stuns.can include 56.39
visits with chill,and intensive r..: more than I person.
coordination of multiple
i.e.family therapy.for
sen ice.. Pil ,
9-1.huun.•lmonthh.
31/2 $31.06 ,,:.r,n $23.93 '
r.
n+—
$25,6I .# .,•
ongoing crisis inter ention as
4 needed,which include.high
R('C1•' S-:n -II si.,t''' le%el of case management and . . Negotiated
Drop Down (•I'A imohement with child and
prop ider and 2-3 Lace-to face
•
contacts per.%eek minimum. .
\ssessmenl/
I:mcrgency $26.96 ',(,h SIK.SK
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
4111
THIS AGREEMENT is made and entered into this/ / day of le 20/V,
by and between the Board of County Commissioners of Weld County, on behalf of the Weld
County Department of Human Services,whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County,"and Sommerfeld,Angela and Robert,whose address is
6710 W 21st Street Lane, Greeley, CO 80634, hereinafter referred to as, "Contractor." This
Agreement covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the 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 September 2, 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.
39/ 7
CWS-7A Individual Provider Contract I Revised 8/2014
2. To safely provide the 24-hour physical care and supervision of each child until
removed or until the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and
participate in the development of the Family Service Plans for children in
placement, including visits with their parents, siblings, and relatives, or transition
to another foster care facility.
5. 1'o maintain approved standards of care as set by the State Department of Human
Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the
Department.
10. To allow representatives of the County Department to visit the foster home and to
see the child at any reasonable time.
11. To give the County Department two weeks notice, except in an emergency,to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or
other persons in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or
supervising agency.
CWS-7A Individual Provider Contract 2 Revised 8/2014
i. Any information received regarding a change of address of the parents or
guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of
1973, and the ADA of 1990, concerning discrimination on the basis of race, color,
sex, age, religion, political beliefs, national origin, or handicap, and to provide
confidentiality of information concerning the child in compliance with the Health
Insurance Portability and Accountability Act(HIPAA).
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family
Homes or Specialized Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as 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 ail rules and regulations of the Colorado
Department of Human Services,the Colorado Department of Health Care Policy
and Financing (if appropriate),the State of Colorado and any applicable federal
laws and regulations, as such, which may be amended from time to time, and shall
be binding on Contractor and control any disputes in this Agreement.
23. To maintain a current license and maintain license requirements as specified
under State law and rule.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times during the term of this Agreement a liability insurance
policy of at least$25,000 for property damage liability, $150,000 for injury
and/or damage to any one person, and $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
CWS-7A Individual Provider Contract 3 Revised 8/2014
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records,documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection, review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child,such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 8/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services,the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form,which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are,or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied,to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County,nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement,if in State of Colorado, county,or federal funds,
whether in whole or in part,is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation,renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 8/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports,on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement,where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes,war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
3. 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 8/2014
public transactions (federal, state,and local) terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
1. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County,or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees,and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five(5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the County
Director. The term"litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 8/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
ATTEST: W BOARD OF COUNTY COMMISSIONERS
Weld minty Clerk th WELD COUNTY, COLORADO
By: � � �'.�;_.; =�« I t � C) ' .1
Deputy 1 Jerk t. � .fiC � Dougla. 'ademac er, Chair I 7
1 ► : ,► DEC 2014
APPROVED AS TO FUN I ' "" APPROVED AS TO SUBSTANCE:
---41.1 .da aliVt /1
Controller E1e ted Official or\Depart4hent Ilead
APPROVED AS TO FORM:
.Z22 N /74
Director of General Services
County Attorney
CONTRACTOR:
Sommerfeld,Angela and Robert
6710 W 21st Street Lane
Greeley, CO 80634
By: 09/02/2014
Contractor's (or esignee's) Signature
and Date
By: ,t 'vvtw`k 09/02/2014
Coni actor's (or designee's) Signature
and Date
do/ 4 L5
CWS-7A Individual Provider Contract 8 Revised 8/2014
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement,"hereinafter
referred to as, "County," and Sommerfeld, Angela and Robert,hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit 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# 1654832. These services will be for children who have been
deemed eligible for social services under the statutes,rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services,which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided,the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 8/2014
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System(FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor,or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case,which involves services provided under the agreement.
The Contractor, within five (5) calendar days after being served with a summons,
complaint,or other pleading which has been filed in any federal or state court or
CWS-7A Individual Provider Contract 10 Revised 8/2014
• • administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
1. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FID0S.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended,proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not,within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7A Individual Provider Contract 11 Revised 8/2014
• a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B)above.
D. Have not within a three-year period preceding this Agreement,had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 8!2014
I, llIH1l 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 followin seven 7 uestions are mutual) 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. I-low much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4.How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P5. 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.
11. How often are therapy services needed to address child's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) -- Behavioral Assessment
Assessment Areas: I Comment: Rating:
Aggression/Cruelty to Animals Select One
Verbal or Physical Threatening Select One
❑ Destructive ofProperty/tire Setting Select One -
❑ Stealing Select One
❑ Self-injurious Behavior Select One
❑ Substance Abuse Select One
❑ Presence of Psychiatric Symptoms/Conditions Select One
Enuresis/Encopresis Select One
Runaway Select One
Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior _ Select One
❑ Delinquent Behavior Select One
❑ Depressive-like Behavior — Select One
❑ Medical Needs-(If condition is rated"severe",please Select One
complete the Medically fragile NBC)
❑ Emancipation Select One
❑ Eating Problems Select One
❑ Boundary Issues Select One
❑ Requires Night Care Select One
❑ Education Select One
�❑ Involvement with Child's Family Select One
Exhibit 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)
x'.,ka n A ge:' >11�y Kg'7', vivo. :Frit ti 4 , Ts � . , fir. ,0 lit
y (�� t =!. .,,L,,,,;6: ::-..2„,.r
..,,,,:,..,,,:,;.01,-:,
XVEL. �s 13IED « w r , '� M.k. Ltetl t CAL
ia�7 '.4• Lir 'OP. ' . ti.
icy .. N ,..:} t'i P+.+}, $: ,F i.,i ,"'3,4 , I �C '
,tEitVICE t '' 7 h •
%�z , tw ' n. 1il C k a -tf'''...'11"111!rakite- t `7
,S47.i)1i7"'°1:gij •a t r.1,w - . t:4 St Lr T ti ] � fin
1 ifi ' t '~ �7 1.4. --g `,. `-l(4 ' r i'AllotL't7' w Am iii e '-__77-:-'-f:-.. ,,;
r v
�' ycL _t D 1 .te_ >_>g R - .: Datl Rate -I: :� figilt ply:R'e ad ate
y:4 1 ,. .F u.'.! `�: dry?. y -...5 ..t. .:.10.144-,4,_fl 'tk i!1' ' Ma ,, 4 4s'
�' :* $12.14 '1',
County Basic ,..4 Age 0-10...S16 73 �, $,66 No crisis intervention,Minimal $0.00 '..
Maintenance !A—. Age 11-14...$18.50 -^`.t: {, Not needed or cover
.�' .. CPA involvement,one face-to-
Rate ."4-1 A e 15-21...$19.75 � '' ' 5; under Medicaid. -i;
S =9'� face visit with child per month. r "•kir.
- $15.51
�' $5.05 x4
Minimal crisis intervention as Regularly Scheduled
1ii
$20.22 '1,,i1!:, nee
-. $-66 needed,one face-to-face visit f t S 39'
:' y•0 therapy up to 4 t:
per month with child,2-3 t5 hours/month. ��.-
' contacts per month
r- ,t .
1 'h -:, $23.59 ..' a.66 ' $17.l9 - ---- ,.„.
—
u
' 7.7
rIvzi, �`;' $18.88 i
$10.11 .....
Occasional crisis intervention as f Weekly scheduled
2 $26.96 x+.66 • needed,two face-to-face visits ' therapy 5-8 hours a F'- $4.S9
month with 4 hours of ''
2_ F
with child,_ 3 contacts per i =
:
month group therapy.
' ,q4,... i ...
2'/a4 $30.331 $.66 $20.56 ---------- 0*
u
' "r $22.24 $15.16
4
"'` Regularly scheduled
Ongoing crisis intervention as ;,4 weekly,multiple
3 f $33.70 ttZ 5.66 4,1needed,weekly face-to-face sessions,can include $6 39
visits with child,and intensive more than 1 person, r
x' ≥' N,� coordination of multiple s ,
3K; Lc.family therapy,for
h; _: services. r,
;: ?, a 9-12 hours/monthly.
3 1/2 $37.06 4�` $.66 �C $23,93 f ----------
-� $25.61
a "x Ongoing crisis intervention as
4 needed,which includes high i;a
5..
47; .; . Neatiated
RCCF $40.44 S.66 level of case management and ,
Drop Down '' x CPA involvement with child and '4$
g 3.a provider and 2-3 face-to face S.,
,tam Ail
i M"
444 t4f contacts per��w��eek minimum. '_% -t
, I ` ft: 171,., ... ti°'F,t 3�i C 'Sr'H 7�-=i t�.. m, 1_^'4' aa�.. *+e.� n v vim. F i`� ' " g-N
4.�'r_��''ss.-' M1> r �t ,3'*u 71 3�i� �,�1'k '�<*•� r's'C- ,•tl;
c`f�.
..�'::.�WJ'y¢� a :.....,..•.�..,ir'� r-'F.;;.:'ti. �.�L. � S':,a; �'-...al��,..4-.....cf..•.., !.. ,�,fi v.4.a.YKC,�t �.s.? rX'- ��
l
Assessment/ ' lE
1� i
Emergency $26.96 $.66 ' ,'' — -
,L.
$18.88
3
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 j�day of Pf 8 20/,1",
by and between the Board of County Commissioners of Weld County, on behalf of the Weld
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Stone, Mary and Jamie, whose address is 10112 W
13th Street, Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the 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 August 18, 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.
00/4- 3V(--
CWS-7A Individual Provider Contract I 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.
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:
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
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.
1. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. 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
W
�l � ' s ';`' - County, on behalf of the Weld County Department
� • V,...of Human Services
ATTEST: �; 0'';
By: "BY. (R ra vn�
Deputy C rk t a ,,.• ,_� Dou ras Radem her, Chairman DEC 1 7 A
�' ::.• R- -. CONTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT Stone, Mary and Jamie
OF HUMAN SERVICES 10112 W 13th Street
Greeley, CO 80634
By: By:tl;0,,,GC.,.. . 08/18/2014
my Di -ctor's ( r deli nee's) Contractor's(or designees) Signature
'i iature, d Date Tarr Date
By: ' 08/18/2014
Contract is(or designee's) Signature
V 1.0Z/8 l•/80 and Date
bl-OZ/8 1,/80
i (72V47- 9 /6
CWS-7A Individual Provider Contract 8 Revised 6/2014
APPROVED AS TO SUBSTANCE:
5e Pja vio.ts PAGE
Elected Official or Department Head
NIA
Director of General Services
APPROVED AS TO FUNDING:
1 �
111� d 6-Atntl
Controller
APPROV�O FORM:
County Attorney
a,0i_ 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 Stone, Mary and Jamie, hereinafter referred to as, "Contractor."
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit 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# 1653349. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4°i 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.
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 Providcr 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.
Pl. How often does the child require transportation by the foster care provider for the following: Select One
Therapy;Medical Treatment:Family Visitation;Extraordinary Educational Needs;etc.,as outlined
in the treatment plan?
P2.How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing,growl-ling,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 arc thera• services needed to address child's individual needs •erNBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cruelty to Animals Select One
❑ Verbal or Physical Threatening Select One
❑ Destructive of Property/Fire Setting Select One
❑ Stealing Select One
❑ Self-injurious Behavior Select One
❑ Substance Abuse Select One
—❑ Presence of Psychiatric Symptoms/Conditions Select One
❑ Enuresis/Encopresis _ Select One
❑ Runaway Select One
❑ Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
❑ Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
Medical Needs-(If condition is rated"severe",please Select One
El
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 Seri ice
Needs Based Care
Rate Table
(Effective 7/01/2014)
V
LEVEL OF (II1LD RESPITE ADMINISTRATIVE ADMINISTRAT1VEe *. ''MEDIcAL
SERVICE- MAINTJNANCE MAINTENANCE SERVICES NEEDS,y
Level ','Daily Rate k!o Daily Rate; Daily Rate ;.. Daily Rat_a :' Daily Rate •
S12.14
County Basic Age 0-10...$16.73 $0.00 •
5.66 No crisis intervention,Minimal Not needed or cover
Maintenance Age 11-14..$18.50 CPA involvement,one face-to-
Rate Age 15-21..S19.75. 4 - under Medicaid.
face visit with child per month.
S15.51 S5.05
Minimal crisis intervention as - Regularly Scheduled -
1 $20.22 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
114 $23.59 S.66 S17.19 ---------
518.88 SI0.I1
Occasional crisis intervention as Weekly scheduled
2 S26.96 5.66 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. .
mmi ME ..-1 /-
2 % 530.33 5.66 0.4 S20.56 -------- --------
w. 522.24 S15.16
Regularly scheduled .
Ongoing crisis intervention as weekly,multiple
3 $33.70 5.66 needed,weekly face-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 5.66 S23.93 --------
- - 525.61
Ongoing crisis intervention as
4 needed,which includes high
RCCF 540.44 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/
Emergency S26.96 5.66 518.88 ---------- ---------
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
y THIS AGREEMENT is made and entered into this / / day of "Pt%F'.aBei, 20 /PI-,
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 Vargas, Jolene and Jose, whose address is 549 W
South 1st Street, Johnstown, 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 August 22, 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.
/V— .3 7 —
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.
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 (HTPAA).
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.
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 finds 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, wan-ants, 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.
NI. 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
CNS-7AIndividu:l 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
C� f}iC '/ County, on behalf of the Weld County Department
ATTEST: C! `° `-c `y= of Human Services
�2 to 1 \rX :j4.
`t
By BYtt ¢.� 7(er • ��
Deputy erk tc>theipatd-t.• Douglas Rademacher, Chairman DEC 1 7 2014
CONTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT Vargas, Jolene and Jose
OF HUMAN SERVICES 549 W South 1st Street
Johnstown, CO 80534
By: By: 08/22/2014
Co y Direc is (or d signe s) Co tractor's (or designees) Signature
Sin tore and Date and Dat
erBy: 08/22/2014
Contractor's (or designee's) Signature
and Date
o2DiL7- 3 9/6
CWS-7A Individual Provider Contract 8 Revised 6/2014
APPROVED AS TO SUBSTANCE:
SP-8- inV1oUs hit G e
Elected Official or Department Head
NIA
Director of General Services
APPROVED AS TO FUNDING:
e-2)0 ,h)La ( ,yi'#
Controller
APPROT7C:>) FORM:
County Attorney
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