HomeMy WebLinkAbout20143350 MEMORANDUM
xT DATE: October 23, 2014
ELT' TO: Douglas Rademacher, Chair, Board of County Co missioners
G O N T - FROM: Judy A. Griego, Director, Human ices epart 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
May 22, 2014, and approved for placement on the Board's Agenda.
The major provisions for these Agreements are as follows:
No. Provider/Term Facility Type/Location Daily Rate
1 Arnett, Casey and Lindsay Foster Home $16.73 - $40.44
July 1, 2014 —June 30, 2015 Loveland, Colorado
2 Brown, Rachel Foster Home $16.73 - $40.44
July 1, 2014 —June 30, 2015 Greeley, Colorado
3 Buck, Jamie and Lynne Foster Home $16.73 - $40.44
July 1, 2014 —June 30, 2015 Evans, Colorado
4 Bunton, Sammy and Stephen Foster Home $0 —No Pay
July 1, 2014—June 30, 2015 Evans, Colorado Licensed by Weld
County only
5 Crews, Paul and Kim Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015
6 Eckhardt, Shawna and Michell Foster Home $16.73 - $40.44
July 1, 2014 —June 30, 2015
7 Egbert, Katie Foster Home ICPC Rate —
July 1, 2014 —June 30, 2015 Auburn, Washington Washington State
8 Fritz, Nancy and Foster Home $16.73 - $40.44
Aughe, Christopher Evans, Colorado
July 1, 2014 —June 30, 2015
9 Granquist, Derek and Jacqueline Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Milliken, Colorado
10 Irwin, Jeremiah and Kasi Foster Home $16.73 - $40.44
July 1, 2014 —June 30, 2015 / I Loveland, Colorado
o�sen f da� C C / 2014-3350
C
io/a7�enak,y 16- 01-12-1
6- 0 HC ooS5
11 Kusluski, Gary and Selinda Foster Home r $16.73 - $40.44
July 1, 2014 June 30, 2015 Windsor, Colorado
12 Maronek, Dennis and Patricia Foster Home $16.73 - $40.44
July 1, 2014 —June 30, 2015 Greeley, Colorado
13 Miller, Linda Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Greeley, Colorado
14 Miller,Pamela Foster Home $16.73 - $40.44
July I, 2014 —June 30, 2015 Greeley, Colorado
15 Pluma, Mike and Annette Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Kersey, Colorado
16 Risler, Jason Foster Home $16.73 - $40.44
Hadley-Riser, Tamara Fort Collins, Colorado
July 1, 2014 —June 30,2015
17 Sena, Leo and Carol Foster Home $16.73 - $40.44
July 1. 2014 —June 30, 2015 Windsor, Colorado
18 Terry, Royce and Rebecca Foster Home ICPC Rate -
June 28, 2014 —June 30, 2015 Ringwood, Oklahoma Oklahoma
19 Van Den Elzen, Dawn Foster Home $16.73 - $40.44
July 1, 2014—June 30, 2015 Greeley, Colorado
20 Wade, Michael and Jodyne Foster Home $16.73 - $40.44
July 1, 2014 — June 30, 2015 Windsor, Colorado
21 Willert, Melody D and Foster Home $16.73 - $40.44
Lee. Kimberly LaSalle, Colorado
July 1, 2014 —June 30, 2015
22 Wurtz, Drew and Foster Home $16.73 - $40.44
Workman-Wurtz, Katherine Greeley, Colorado
July 1, 2014—June 30, 2015
23 I Yingling, David and Nicole Foster Home $16.73 - $40.44
July 1, 2014 —June 30, 2015 Wellington, Colorado
24 Simmons, Michael and Hava Foster Home $16.73 - $40.44
July I, 2014 —June 30, 2015 Windsor, Colorado
If you have questions. please give me a call at extension 6510.
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this al day of 0thin 20 Pt,
by and between the Board of County Commissioners of Weld County,on behalf of the Wel
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Arnett,Casey and Lindsay,whose address is 1545
Chickadee St., Loveland, CO 80537, hereinafter referred to as, "Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS,the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as"Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014, to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 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:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied,to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of {
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
4
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:
I. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local)terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
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 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: ?_ �'�; of Human Services
'
/
By: ��, � ` ,4ys DIY (. ( G ) Gi1 �.
Il eputy Clerk to e • �,. �� i` 1 Barbara Kirkmeyer, Pro-Tem
fFiIO 'c) CONTRACTOR: OCT 2 7 1014
Approval as to Substance: ♦ ���
WELD COUNTY DEPARTMENT Arnett, Casey and Lindsay
OF HUMAN SERVICES 1545 Chickadee St.
Loveland, CO 80537
n
BY: . \l � BY:
my Dir ctor's desi lee's) Contractor's ordesignee's) Signature
i azure d Date and
By:
tor's (or designee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
204-3550_
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Arnett, Casey and Lindsay, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
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# 1614609. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid,will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 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 J
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. i
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 r t Revised 6/2014
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B)above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions(federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7) questions are mutually exclusive.
PI. How often does the child require transportation by the foster care provider for the following: Select One
Therapy;Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
PS. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing,grooming, physical,and/or occupational therapy?
Al. How often is CPA/County case management required?(Does not include therapy) Select One
"Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
T1. How often are there. services needed to address hild's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
U 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
U Presence of Psychiatric Symptoms/Conditions Select One
❑ Enuresis/Encopresis Select One
❑ Runaway Select One
(J Sexual Offenses Select One
U 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
O 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) �1I
Tf�� ` rC*PY7' Grl - lF
40,1m7:4;'11.,!4;.2.7,-
nj� r11) Jry le ( /n ,.,r,1 ttA1 i9>Y�aaA,L, -:.,,. t, •p J61Ft r /0 170 �x,
�1, 1 A4 '' .K ,.d L,P &-i5-,G'r �a..-.t. -4t'' �f ;Ti srp 'z,,"(ci -sok' -`]Y' I,tMrAv
i(
f - ��
;i d E '"" �'—',.',.Et a34p icr 3P. ,,x �e! _,� 2 ,,-.4.' i� i,1t� ,.: �! ,n�nSP, ..
I
' ' "r. $12.14 d,,..
County Basic r t Age 0-10...S16.73 't,. $,66 r No crisis intervention,Minimal ;;Tolat:ndle-er:d0;00r
Maintenance Aell-14...$18.50 cover ------
g CPAinvolvement,oneface-to-Rate Age 15-21...$19.75 - :c� Medicaid ,rr
face visit with child per month.
.-I._
$15.51 $5.05
y ir-i-.
? Minimal crisis intervention as Regularly Scheduled
1 $20.22 x $.66 needed,one fact to-fae visit $3.39
therapy up to 4 .per month with child,2-3 hours/month.
RIcontacts per month '
1 'h $23.59 $.6Gif
$17.19
"" $10.11
$18.88 w.
V. Occasional crisis intervention as Weekly scheduled
2 $26.96 $.66 J needed,two fact-to-face visits therapy 5-8 hours a $4.89
^ti with child,2-3 contacts per z month with 4e hours of
month t: group therapy
•
2 G $30.33 $.66 $20.56 -•----- - ------•—
t,� $22.24 $15.16
.� Regularly scheduled is
Ongoing weekly,multiple
needed,weeklycrisisintervention face-to-faceas
3 $33.70PT $.66 sessions,can include $6.39
Fic. visits with child,and intensive more than I person
s 1'4coordination of multiple ''
fir, i.e.family therapy for
M.
"r: services. 9-12 hours/monthly.ti=
$23.93
31/2 $37.06,, 5.66
$25.61
I It. Ongoing crisis inteention as
4 - • - needed,which inclurvdes high k;.
RCCI $40.44 ' $.66 $' level of case mm�ugement and .fr --------' Negotiated
Drop Down Q,� CPA involvement with child and '�J�'
t provider and 2.3 face-to face
contacts per week minimum
vativikes r -
qn
Assessment/ ,..
a" $18.88
Emergency P $26.96 j $.66
rtLevel Rate
Exhibit C to the Additional Provisions Revised 6/2014
14
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this day of Oehoie- , 20/
of County, on behalf of the Weld
the of County Commissioners Weld Cou
by and between Board Y,
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Brown, Rachel,whose address is 2809 W E. Street,
Greeley, CO 80631, hereinafter referred to as, "Contractor." This Agreement covers all children
placed by County with Contractor.
WITNESSETH:
WHEREAS, the 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
I a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014, to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30)days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty (30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
I. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
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.
I I. To give the County Department two weeks notice, except in an emergency, to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or
other persons in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or
supervising agency.
CWS-7A Individual Provider Contract 2 Revised 6/2014
i. Any information received regarding a change of address of the parents or
guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of
1973, and the ADA of 1990, concerning discrimination on the basis of race, color,
sex, age, religion, political beliefs, national origin, or handicap, and to provide
confidentiality of information concerning the child in compliance with the Health
Insurance Portability and Accountability Act(HIPAA).
IS. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family
Homes or Specialized Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal
personnel. The records shall document the type of care and the term during which
care is provided for each child. In addition, medical, educational, and progress
summary records shall be maintained for each child in accordance with Volume 7
requirements.
21. To maintain medical, dental and educational records for each child/youth and
supply updated information to the County Department.
22. To conform with and abide by all rules and regulations of the Colorado
Department of Human Services, the Colorado Department of Health Care Policy
and Financing (if appropriate), the State of Colorado and any applicable federal
laws and regulations, as such, which may be amended from time to time, and shall
be binding on Contractor and control any disputes in this Agreement.
23. To maintain a current license and maintain license requirements as specified
under State law and rule.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times during the term of this Agreement a liability insurance
policy of at least $25,000 for property damage liability, $150,000 for injury
and/or damage to any one person, and $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
CWS-7A Individual Provider Contract 3 Revised 6/2014
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records, documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection, review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
I. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
I. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance ofa child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
Ill. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens,County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
1. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state,or local)with commission of any of the offenses
enumerated in paragraph (B)above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions(federal, state, and local)terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
1. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement,or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5)calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST:C�(i j/ , w %f Human Services
.,rLlflr�►J W/
By: l..l.�� !' i, , Z :
ue ut Clerk to th= o r,� '�.: �' 1
P Y �,.. ' Barbara Kirkmeyer, Pro-Tem
CCT2i 2014
4®tit r jO NTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT Brown, Rachel
OF HUMAN SERVICES 2809 W E. Street
Greeley, CO 80631 By: By: rneaftt 'L�/L/
/y
my ector or de ignee's) Contractor's or designee's) Signature
i ature nd Da and Date
By:
Contractor's(or designee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
MN-3350
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Brown, Rachel, hereinafter referred to as, "Contractor."
GENERAL PROVISIONS
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# 1640956. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 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 6/20 14
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:
I. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
1 I. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
CWS-7A Individual Provider Contract I I Revised 6/2014
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions(federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven(7)questions are mutually exclusive.
P1. How often does the child require transportation by the foster care provider for the following: ' Select One
Therapy: Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined
i in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
I sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling i Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond age Select One
i appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy?
F How often is CPA/County case management required?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
I Tt. 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: Ratin.:
y A•_ression/Cruelt to Animals Select One
■� Verbal or Ph sical Threatenin: Select One
■ Destructive of Property/Fire Setting Select One
Stealing Select One
Self-in'urious Behavior Select One
■ Substance Abuse Select One
Presence of Psychiatric Symptoms/Conditions Select One
■ Enuresis/Enco.resis Select One
■ Runaway Select One
❑ Sexual Offenses Select One
Li Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
IM Delinquent Behavior Select One
■ Depressive-like Behavior Select One
Medical Needs-(If condition is rated"severe",please Select One
❑ complete the Medically fragile NBC)
❑ Emancipation Select One
■ Eatin: Problems Select One
■ 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
r EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014) �
•-•e,•'-T,{4 a,Pew ..—.wcr 1T..CW
#"sn
$12.14
County Basic .t Age 0-10...$16.73 - $0.00 w"1
rt. $.66 ` No crisis intervention.Minimal ves
Maintenance s< Age l l-I4..$18.50 = y',, Not needed or cover „
Rate Age 15-21...$19.75 m CPA involvement,one(ace to under Medicaid
face visit with child per month. {y
$15.51 u $5.05
t* ,
i- Minimal crisis intervention as i Regularly Scheduled 83.39
I " $20.22 $.66 44 needed,one face-to-face visit + therapy up to 4
e„; per month with child,2-3
ax hours/month
contacts per month
1 % 'i $23.59 $.66 " $17.19
3c...0.
J -------'
6 0.
$18.88 $10.11 Elk
_; Occasional crisis intervention as ;, Weekly scheduled a
2 w $26.96 $.66 needed,two face-to-face visits � therapy 5.8 hours a rtfri $4.89
with child,2-3 contacts per ""' month with 4 hours orili f
month �':}' group therapy. -
R,
2 Y, $3033 $.66 r $20.56 r9,-:, -••—.....
.„1'`° $22.24 $15.16 - ''
pt..; t`- ' Regularly scheduled
'a91 Ongoing crisis intervention as weekly,multiple ----I,x, a'v.. $66 needed,weekly face-to-face - sessions,can include �' $6.39
3 $33.70
visits with child,and intensive y.t" more than I person
11'41 coordination of multiple977 i.e, family therapy for
... services.it -aa 9.12 hours/monthly
} 12 .' $37.06 - $.66 $23.93 w
.1'''' $25.61
Ongoing crisis intervention as
4 L* -r needed,which includes high 4j
RCCF' _ $40.44 .r.'' $.66 _tee level of case management and Negotiated
y
Drop Down 7--. 4"0 CPA involvement with child and iI
provider and 2-3 face-to face :?-
contacts per week minimum. ' •.-_.:::Liar
5, `. ,P ,r, L" <s.... .,� a te_, d ;`tilt+: .,. .�rcwN+ -- c !C,�-.., ? - -
1 y
Assessment/ L,—
Emergency $2696 $.66 $18.88 '
is.- a I
Level Rate Ar
. sir.. ... -
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 thisto day of Cr, 20 /y,
by and between the Board of County Commissioners of Weld County, on behalf of the Weld
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Buck,Jamie and Lynne, whose address is 6455
Chardonnay St. #3,Evans, CO 80620, hereinafter referred to as, "Contractor." This
Agreement covers all children placed by County with Contractor.
W ITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014, to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty (30)days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty (30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
I. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
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 (HIPAA).
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family
Homes or Specialized Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal
personnel. The records shall document the type of care and the term during which
care is provided for each child. In addition, medical, educational, and progress
summary records shall be maintained for each child in accordance with Volume 7
requirements.
21. To maintain medical, dental and educational records for each child/youth and
supply updated information to the County Department.
22. To conform with and abide by all rules and regulations of the Colorado
Department of Human Services, the Colorado Department of Health Care Policy
and Financing(if appropriate), the State of Colorado and any applicable federal
laws and regulations, as such, which may be amended from time to time, and shall
be binding on Contractor and control any disputes in this Agreement.
23. To maintain a current license and maintain license requirements as specified
under State law and rule.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times during the term of this Agreement a liability insurance
policy of at least$25,000 for property damage liability, $150,000 for injury
and/or damage to any one person, and $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
CWS-7A Individual Provider Contract 3 Revised 6/2014
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records, documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection, review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency.An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
II. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
I. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions(federal, state, and local) terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
1. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
/ County, on behalf of the Weld County Department
ATTEST: ,yZ`If J G: .vC of Human Services
SiLa�
By: Ufa
e ut Clerk to th- Lo ,:A
p Y �� arbara Kirkmeyer, Pro-Tem
30 0 •T TRACTOR: OCT 2 7 alga
I
Approval as to Substance:
WELD COUNTY DEPAR p pv ;,�'1uck, Jamie and Lynne
OF HUMAN SERVICES _ 6455 Chardonnay St. #3
Evans, CO 80620 •
By:
y Dictors desig 's) ontractor's(or designee's) Signature
g1nt
ature nd Date and ate
—02—/4/
tractor's(or designee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
AC/4-3350
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Buck,Jamie and Lynne, hereinafter referred to as, "Contractor"
GENERAL PROVISIONS
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 111/4 1643264. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided,the County reserves the right to
deny payment.
B. Be submitted by the 4`h of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five (5)calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
CWS-7A Individual Provider Contract 10 Revised 6/2014
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
I. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
I I. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
CWS-7A Individual Provider Contract 1 I Revised 6/2014
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions(federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7) questions are mutually exclusive.
Pt. How often does the child require transportation by the foster care provider for the following: Select One
Therapy; Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. 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?
I 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?
I
Al. How often is CPA/County case management required?(Does not include therapy) 1 Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
T1. How often are thera. services needed to address child's individual needs •er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
III ❑ 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
ir Presence of Psychiatric Symptoms/Conditions _ Select One
Enuresis/Encopresis Select One
71 Runaway Select One
o Sexual Offenses Select One
H 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
D
complete the Medically fragile NBC)
❑ Emancipation Select One
Eating Problems Select One
Boundary Issues Select One
Requires Night Care Select One
Education Select One
-ti Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
1
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
- ".iii.-- `Cv c^x..771" .µWS ,zr:::- -
t„w � e '''.^:::.c.;,..- ... ,: ,Ska"i'ry -1“. ',...* `,.qp i _�Nn L, f - '
''fall
1 . di
k_ .e
County Basic + Age 0-10...$16.73 ..- $12.14 $0.00
Maintenance 'r Age l 1-14...$18.50 ' 5.66 > No crisis intervention,Minimal Rtr? Not needed or cover ✓"
Rate Age 15.21...519.75 '-�, CPA involvement,one face to under Medicaid.
:2 face visit with child per month.
-44
^' ; 515.5 I 55.05
•l Minimal crisis intervention as Regularly Scheduled .
1 520.22 5.66 needed,one face-to-face visit 33.39
therapy up to 4
-al. per month with child,2-3 t°1" hours/month
—= Ashi contacts per month •
1 / $23.59 = x $.66 $17.19 ..` -----••-
ri = 518.88 '"� $10.1 1
' Occasional crisis intervention as a airs I•icaWeekly scheduled
2 ,„.,.; $26.96 ''1 5.66 needed,two face-to-face visits therapy 5-8 hours a 54.89
r with child.2-3 contacts per month with 4 hours of
` .. month group therapy.
'h- F3
r
2 '/, 530.33 ' 5.66 74
$20.56 '- — ••----
" led $22.24 $15.16
4- ,. ' Regularly scheduled
Ongoing crisis intervention as weekly,multiple
3 $33.70 $.66 '`*�3 1-4 needed,weekly face-lo-face sessions,can include ri.-. $6.39
stv visits with child,and intensive k' more than I person
;S. coordination of multiple .k+. '
i.e. family therapy for
tra Li, SM.ices l.fil. 9-12 hours/monthly a
3 I/2 $37.06 • $23.93 .
vw
'Pe $25.61 - 4
. `:• ,-,, Ongoing crisis intervention as - -y
4 - needed,which includes high 1
lt
?
RCCF iii- $40.44 . level of case management and -. Negotiated
iirvii ' CPA involvement with child and P-7" s' y
Drop Down ,,,,
aq iA provider and 2-3 face-to face a"_
: `.- contacts per week minimum. ;2
,_. ..,.. r y ... -mss
t� ,..
Assessment/ _ 04p.
Emergency x, 526.96 " $r'l .66 ,„ $18.88 -------
Level Rate
Exhibit C to the Additional Provisions 14 Revised 6/2014
L.
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this \{ day of kry4,--- , 20 FA .
by and between the Board of County Commissioners of Weld County, on behalf of the Weld
County Department of Human Services, whose address is P.O. Box A, Greeley. CO, 80632,
hereinafter referred to as, "County,"and Bunton, Sammy and Stephen, whose address is 3405
Burlington Ave,Evans,CO 80621, hereinafter referred to as, "Contractor." This Agreement
covers all children placed by County with Contractor.
W ITNESSF.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 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 I Revised 6/2014
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
I. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
2. To safely provide the 24-hour physical care and supervision of each child until
removed or until the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and
participate in the development of the Family Service Plans for children in
placement. including visits with their parents, siblings, and relatives, or transition
to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human
Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the
Department.
10. To allow representatives of the County Department to visit the foster home and to
see the child at any reasonable time.
II. To give the County Department two weeks notice, except in an emergency, to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department. as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
CWS-7A Individual Provider Contract '_ Revised 612014
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 (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
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:
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.
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. 'fhe 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.
I 1. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child
in writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
CWS-7A Individual Provider Contract 5 Revised 6/2014
III. GENERAI. 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 he released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement. Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services 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 he
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws
of Colorado and be in accordance with the policies, procedures. and practices 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
public transactions (federal, state, and local) terminated for cause or default.
CWS-7A Individual Provider Contract 7 Revised 62014
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope of
work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include, but
are not limited to. any one or more of the following:
1. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement,or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement. and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge
and agree that no part of this Agreement is intended to circumvent or replace such
immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five(5)calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency. shall deliver copies of such document(s)to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
C'WS-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
County, on behalf of the Weld County Department
ATTEST: of Human Services
By: �I/� `� �:�"� _1t \_" ' /1/U/'
i eputy Clerk to the :oa
1861 '. � rbara Kirkmeyer, Pro-Tem
1 OCT 2 7 2014
Sj RACTOR:
Approval as to Substance: ,� A /'
WELD COUNTY DEPARTM I:unton, Sammy and Stephen
OF HUMAN SERVICES 3405 Burlington Ave
Evans. CO 80621
By: By: 0cif ILI I �1
unty hector' (or de t Knee's) ontract ' (or designee's)Signature
S.tnatur and D and Date By: 1� � p4/WC tractor's(or designee' ignature
and Date
CWS-7A Individual Provider Contract 9 Revised 6/2014
ao/4 3357)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this A / day ofCto 20
by and between the Board of County Commissioners of Weld County, on behalf of the Wel
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Crews, Paul and Kim,whose address is 407 7th
Street, Mead, CO 80542, hereinafter referred to as, "Contractor." This Agreement covers all
children placed by County with Contractor.
W ITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as"Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014,to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty (30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 1 Revised 6/2014
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 toss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records, documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection, review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/20!4
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
1. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement,had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local)terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
P Y g
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: WJ . of Human Services
a
By:
y: t �.l << tiw A�/icj/ ;-
Deputy Clerk to j Barbara Kirkneyer, Pro-T/ern
OCT 27 2014
,� CONTRACTOR:
Approval as to Substance"4O
WELD COUNTY DEPAR Crews, Paul and Kim
OF HUMAN SERVICES 407 7th Street
Mead, CO 80542
By: 1 By: F lfi
my DI ctor s r deli ee's) Co a ors (or designee's) Signature
Si nature nd Dat and Date
Li
By: �1'
Contractor's r designee s) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
aoW- 0
EXHIBIT A to the CWS-7A
Additional vi i Pro sons for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Crews, Paul and Kimberly, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
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# 1648992. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays,deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4`h of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
CWS-7A Individual Provider Contract 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
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
y
i 3: } ' }WT ililj n 'F 3��pi �i V 1 - t':Y IK . " W'P f* b'fl 4' y 4tlYlll'I d hll .:
i` i' -0" g i t nil?, iii -k ! S� I K{r- t:7*mk,+, I kt^ s .
ZitSKELVI ` 're v ' m,l s. I I {- o ''' I 91 ' I al a�yyu�4^r �' +tl
'` "Y��..-y{l i.-{�: IS �.. i�72 i .p� Bie6fe` Cd 2 '�i:p '
SEY2V EII � A >3 y l 1 9 .lim7 ,S
rl `'z 3'w' t4' �. "4k- rv"".r [ LIL `Y' a ! ,-� e45519:317r ry n
5 I y �i. o ta-e n r ` mi t a' 'F'" k itrs Md ` 1 t Y''- k t luT.�4 g$ i'
' aI t'i4°d vf ,+v' h a+a °t7 t� aut.r r'i z�4 ge Y' 1 Alig'r= -14 P -nSd-E�"il s r ,�
Letrel r .1).91 ren a f -t +6 w m ti t r I�' ' "� � 4 naiTY Pit ,
I � fir. +�jl ea, s D
" : i�i) M iE.Yc++ctit..ir�kri 11 �im.Fl.-4.4 L: q-(-4'.ai44.Oi� •000�.irilP "''Hi iw 41
Riii X11.�6 Cl Ta
County Basic Age 0-10...$16.73 °' fit
$12'14 Iz' $0.00-iiit'ii MIS ��T,
Maintenance A;iittge 11.14...$18.50 .�;F 5.66 No crisis intervention,Minimal n x _ —
`a. pis Not needed or cover
Rate Age I S-21...$19.75 k,'elli` wt CPA involvement one face-to- 'ar
g i. �,,, under Medicaid
.,« ,; face visit with child per month - r
...ay
f:
zs $15.51 ,,,,P3:
$5.05
Ilici
'iii; Minimal crisis intervention as yr.
1 $20.22 �s $.66 [ : Regularly Scheduled
t'- z '4-'91 needed,one face-lo-face visit ;; $3.39
k4 IWElib; therapy up to 4 , .
per month with child,2-3 'T° i<r v
hours/month. :iliM
- iy (0 - contacts per month - wb
ill
1 %: $23.59 m $.66 l'i'i $17.19 #""y _______— i�'. _.._�.
_t,: 4 ,. i lit
tW Vn $18.88 1::1 $10.11Lei-
�" f Occasional crisis intervention as liil Weekly scheduled >}
ii
2 �' $26.96 $.66 k2 needed,two face-to-face visits rs' therapy 5-8 hours a ?- $4.89
c )k with child,2-3 contacts per ill month with 4 hours of x r
za„ f al month 3f group therapy n
2': ''7mit
.rx17-1 $3033 'L $.66 } $20.56 --------- ,'i --
y;; c! $22.24 ' $15.16 syi;,
9"3 i Regularly scheduled ..
-' �&i `., Ongoing crisis intervention as p i. weekly,multiple 4VA• '
3 ,,,= $33.70 - $.66 t : needed,weekly face-to-face s_ sessions,can include Iq;j $6.39
y? visits with child,and intensive ; more than I person "
IF ; '` coordination of multiple �! i.e. family theca fortilt:
"i, Ian i pY _
ttsiI ,,,M1;, f}! services. I ; 9-12 hours/monthly r
g
3 1/2 $37.06 Nil $.66 {}s: $23.93 ' 4 -- .-------
y g. �tx3'.i- $25.61
P _
+,�_ S * Ongoing crisis intervention as {�
' i
lit,: u ;
�
:P*-::P*-: byl� nee
ded,which includes high V i3,.
RCCF $40.44 1+', 5.66 �. level of case management and ------- }:' Negotiated
Drop Down kA* fll CPA involvement with child and h m; r'
` ' :44'i provider and 2-3 face-to face y'r..9ii.. thl
44contacts per week minimum. Ir
m
:. 1 -c) 1W ..��,- - I . i . ri'&..aIA rl i i''L t '"t V" 3 9
II V:
r'•Assessment/
Emergency $26.96 -4! $.66 SS`$rc $18.88 -----
Level Rate i�ait
2 ?tinsn 6u.
iiiiI a,et
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 thisaj7 day of/O LZ( , 204 ,
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 Eckhardt, Shawna and Mitchell,whose address is 505
54th Ave., Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers
all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, to and until June 30, 2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty (30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 1 Revised 6/2014
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.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
1. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public(federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local) terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
1. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: `j ,'{ j) ( � of Human Services
By
Deputy Clerk to Y .? i ' �� Barbara Kirkmeye , Pro—Tem
r t oce—.�iONTRACTOR: OCT 2 7 2014
Approval as to Substance: ®( r "O
WELD COUNTY DEPARTS:��. � Eckhardt, Shawna and Mitchell
OF HUMAN SERVICES 505 54th Ave.
Greeley, CO 80634
II 1-07-141/
By: l X By:
ty Dire tor's desig e's) Contractor's(or designee's) Signature
g urea _Date and-Date (21
on a or's (or e ' nee Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
ADP -335a
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Eckhardt, Shawna and Mitchell, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
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# 1644218. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
CWS-7A Individual Provider Contract 10 Revised 6/2014
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
1. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7A Individual Provider Contract 11 Revised 6/2014
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7)questions are mutually exclusive.
P1. How often does the child require transportation by the foster care provider for the following: Select One
Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
PS. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding, bathing,grooming,physical, and/or occupational therapy?
Al. How often is CPA/County case management required? (Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
11. How often are thera. services needed to address child's individual needs •er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cruelty to Animals Select One
❑ Verbal or Physical Threatening Select One
❑ Destructive of Property/Fire Setting Select One
❑ Stealing Select One
❑ Self-injurious Behavior Select One
❑ Substance Abuse Select One
Presence of Psychiatric Symptoms/Conditions Select One
❑ Enuresis/Encopresis Select One
❑ Runaway Select One
❑ Sexual Offenses Select One
^❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
❑ Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
❑ Medical Needs -(If condition is rated"severe",please Select One
complete the Medically fragile NBC)
❑ Emancipation Select One
❑ Eating Problems Select One
❑ Boundary Issues Select One
Q_ 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)sil tae r .o.` 0.
'' " N7i t U7yYlpfl�: ,',. '. ''''., yae '� ....,,,,r 1 -I'.4�-,*, 'x ,c, �Y 1 �3 ai 2r '1 '{,N JI IC.'
x _1 r i r ' di 3 :,.`'e,". ;TAI--:'... y F
�4 { ip
'1411.1794r114.
�-R0. ej�Yvq� 1 f!`f�j/e�!-tl� b D,�ym?`ri'�n; '� + � t� Y � r _ � _
f i a g4,S 'v f� d t-s..v.�.�"3 1.._ • � �
o, $12.14 s'e
County Basic 'titAge ,�A � $0.00
g $.66 a No crisis intervention,Minimal Not needed or cover
Maintenance 1 Age 11-14_.$18.50 0 CPA involvement,one face-to- "i,-, • . '' .
Rate t Age 15-21...519.75 -, face visit with child per month. under Medica .
a;d 515.51 ?A 55.05 :
;e 3S •
Minimal crisis intervention as Regularly Scheduled *'
1 $20.22 * . $.66 ' needed,one face-to-face visit to + , 53.39
r + therapy up to 4 yr
m- per month with child,2-3 4 hours/month. 1`
contactsItt per month `•1
1 % $?3.59 ' 5.66 t' $17.19
510.11
. ;`�..
'Sty 4` S18 88 - Weekl scheduled
Occasional crisis intervention as ',fiT > Y
2 $26.96 $.66 'a• needed,two face-to-face visits .° therapy 5-8 hours a S4.89
month with 4 hours of ,
:Y rc Na with child,2-3 contacts per #
r:`. month ', group therapy.
2 Y, 4. $30.33 e" 5.66 f(,,: S20.56 p:
Y `„ 522.24 $15.16
a Regularly scheduled '?
ek t`. Ongoing crisis intervention as weekly,multiple ,',.
needed,weekly face-to-face sessions,can include a $6.39
3 -s) $33.70 5.66 i i,.
''J viti sits with child,and intensive more than I person, a a4
5t coordination of multiple ggg,„"""- i.e. family therapy,for
services. 9-12 hours/monthly.
31/2 S',31-; $.66 523.93 ,
r; c 525.61
k:.
• Ongoing crisis intervention as Sr
4 *t pr. needed,which includes high
RCCF 4 $40.44 $.66 t level of case management andIt— rp; Negotiated
Drop Down ' ' CPA involvement with child and ft
`''' provider and 2-3 face-to face /.+,
v
' *Ast ' contacts per week minimum. Y
yam} �yy:`.. �j 'yF y} 3s
H. `N' t'44”V£� . FR6 4 a ..."-.iS `�6�..
R.
Assessment/ ttt
Emergency $26.96 5.66 $18.88
riC I,
Level Rate 1,?'
Exhibit C to the Additional Provisions l4 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into thine ay of fiejaZ .2014
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 Egbert, Katie,whose address is 214 14th Street SE,
Auburn,WA 98002, hereinafter referred to as. "Contractor." This Agreement covers all
children placed by County with Contractor.
WITNESSETH:
ESSETH:
WHEREAS,the Colorado State Department of Human Services (hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home(hereinafter referred to as"Facility"), and
WHEREAS.Contractor understands and agrees that it must,during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
1. TERM:
A. The term of this Agreement shall be from July 1,2014,to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30)days prior to the intended date of
termination. If notice is so given,this Agreement shall terminate upon the expiration
of thirty(30)days.or until the eligible children)may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease;however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
CWS-7A Individual Provider Contract I Revised 612014
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
I. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
2. To safely provide the 24-hour physical care and supervision of each child until
removed or until the agreement is renewed.
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. 'Fr) maintain approved standards of care as set by the State Department of Human
Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the
Department.
10. To allow representatives of the County Department to visit the foster home and to
see the child at any reasonable time.
I I. To give the County Department two weeks notice, except in an emergency. to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
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(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
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:
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. l'o inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
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.
II. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child
in writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
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 he solely and entirely responsible for its acts or
of any agent, employee. servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado. county. or federal funds.
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county. and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement. Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement. Exhibit A and the Needs Based Care
Addendum are intended to 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.
P. 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 G'?014
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 he held liable for damages.
M. Contractor assures and certifies that it and its principals:
I. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. I-lave not, 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. 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 I., above. County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope of
work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include, but
are not limited to, any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement. and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the panics 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.
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
County, on behalf ofthe Weld County Department
ATTEST: W.d't rti ;ok, of I luman Services
fa La
1 �
By: LL f LI •` ' `.v:
De ut Clerk to : `
eputy � , Barbara Kirkmeyer, Pro—Tc�m
tit
: 4 OCT 2 7 20M
i � NTRACTOR:
Approval as to Substanstr
WELD COUNTY DEPA -gbert. Katie
OF HUMAN SERVICES ` - ; 's" 214 14th Street SE
Auburn. WA 98002
I
By: �, By:
t�s ,i
C ty Dir tor's( desig e's) Cont actor s (Lig4ture
S'g ture a Date and Date
By:
Contractor's (or designee's) Signature
and Date
CWS-7A Individual Provider Contract 9 Revised 6/2014
a'—?35t
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this ViS day of , 20 V{ ,
by and between the Board of County Commissioners of Weld County, on be alf of the Weld
County Department of Human Services, whose address is P.O. Box A,Greeley, CO, 80632.
hereinafter referred to as, "County,"and Fritz,Nancy and Aughe, Christopher,whose
address is 3925 Stampede Dr.,Evans,CO 80620, hereinafter referred to as, "Contractor."
1'his Agreement covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS,the Colorado State Department of Human Services(hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
I tome/Emergency Shelter Home(hereinafter referred to as"Facility"). and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department,and
WHEREAS, County may, but shall not be obligated to, purchase foster care services,and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein. County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014,to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30)days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30)days. or until the eligible child(ren)may be placed elsewhere.
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 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 Revised 6/2014
.,-wrt1M�...,, W^°�.a.�fel3-?ss!11fa9Wi:xiu" X1xu rN11A116&tie:alx•.ha,lt cjw:.,rr...,-...Y.._......-,.t.- sISS t.r.:s.,w,..r.rw w:..;.i'. ww.lw....ac uww.�••••-„r..sanwr:.rr:rt:..i..
•
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 (I IIPAA).
15. To attend core certification training prior to the placement of any child.
16. To attend on going training as required by State Department regulations.
•
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family
I lomes 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 ofColorado 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.
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 tbr the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6.!2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
II. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof
III. GENERAL. PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado,county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children,Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of I(Liman Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further,Contractor
represents, warrants,and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant.employs
illegal aliens or subcontracts with illegal aliens.County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
1. Are not presently debarred, suspended,proposed for debarment,and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement.
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state,or local)with commission of any of the offenses
enumerated in paragraph (13)above.
4. Have not within a three-year period preceding this Agreement. had one or more
CWS-7A Individual Provider Contract 6 Revised 0 20I 4
public transactions(federal, state,and local)terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I.,above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement. Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement,or other agreements between County and Contractor,or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement,and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees,and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor,within five(5)calendar days after being served with a summons,
complaint,or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the County
Director. The term "litigation" includes an assignment for the benefit of creditors.
and filings in bankruptcy. reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
•
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
(� �,,,,// County, on behalf of the Weld County Department
ATTEST: W..d�IGnI sid100.40k of Human Services
By By�� lL-LG ��—
D puty Clerk to th1 ////��,
-a ` ' Barbara Kirkmeyer, Pro-Tem
t�+NTRACTOR: 0CT 2 7 2014
Approval as to Substan • ,t 1� O
WELD COUNTY DE Stz, Nancy and Aughe, Christopher
OF HUMAN SERVICE: ( C 4 25 Stampede Dr.
Ulf N. ; Evans, CO 80620
By: By:
C my Dir ctor's ( design e's) Contracto ' (or esiP e's) Signature
i nature id Date . . Date
B : — •
o 'tracto 's (or designee's) ignat re
an. Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
SOW-3351)
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 Fritz, Nancy and Aughe,Christopher, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit as Exhibit B, shall be used to determine the Child
Maintenance and Medical Needs, if applicable. for each child placed with Contractor
unless the child is placed in a County certified kinship foster care home or a County
foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-
adoptive placements will be reimbursed at the County Basic Maintenance level for Child
Maintenance as indicated on the Needs Based Care Rate Table,designated in this exhibit
as Exhibit C, regardless of the child's level of need.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for the Child Maintenance level of
service, as indicated by the Needs Based Care Rate Table, designated within this exhibit
as Exhibit C, for children placed within the Weld County Certified Foster Care Home
identified as Provider ID# 1539167. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles,or services not covered by Medicaid,will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25)calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall be paid from the date of placement up to.
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement. and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five(5)calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
('WS-7A Individual Provider Contract 10 Revised 6/2014
administrative agency, shall deliver copies of such document(s)to the f luman Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
I I. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
I). Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7A Individual Provider Contract II Revised 6/2014
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement.
theft, forgery, bribery, falsification or destruction of records. making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. I lave not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
('WS-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC(NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7)questions are mutually exclusive.
Pt. How often does the child require transportation by the foster care provider for the following: Select One
Therapy;Medical Treatment: Family Visitation; Extraordinary Educational Needs;etc.,as outlined i K
in the treatment plan? , �'��a u r"e r
y
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 Seles Cane
conjunction with a regular or special education plan? ,' ( 4 1--c r 4"
P4. How often does the child require special and extensive involvement by the provider in scheduling Sect One
and 7 CA r a k e e"(..
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? .2 '' J ' CA`.y
Al. flow often is CPA/County case management required?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling 7 �/<<7J c,C F r(
group
or more than one County foster child is with the same provider. - .
TI. Flow often are theca. services needed to address child's individual needs .er NBC assessment? Select Ore® ,; , 4'
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
El Aggression/Cruelty to Animals Select One _.
❑ Verbal or Physical Threatening Select One
❑ Destructive of Property/Fire Setting Select One _',
R Stealing Select One ,
Self-injurious Behavior Select One r
❑ Substance Abuse Select One
..--- _
E Presence of Psychiatric Symptoms/Conditions Select One
Enuresis/Encopresis Select One .';J
O Runaway Select One
❑ Sexual Offenses Select One . _,r✓
Inappropriate Sexual Behavior Select One _, Yi
Disruptive Behavior Select One Z
❑ Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
❑ Medical Needs-(If condition is rated"severe",please Select One
complete the Medically fragile NBC) ,
O Emancipation Select One r.J
Eating ProblemsR,
Select One —
Boundary Issues Select One L
Requires Night Care Select One r,_,.�
Education Select One4
❑ Involvement with Child's Family Select One .
Exhibit B to the Additional Provisions 13 Revised 6/2014
• *
EXIIIBI f C
Weld County Department of human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
4 7 n •pr. y. _..[ Sys __
d �... • tt.itxgYy, , ,�4
y•4.,11. .- .L. .'.61S�hi:: .. 1i 1 —vAAke C.... . .
f1 147:.. ."241.4.,..,!,...,.V,.a 4. '. am. .,. ....61.-4,443,6.., _i_-iAz11::ti�..,r- .,J_ .-.....t.). ._ :Ai;. +• r
'�'' !..- $12.14
('ounty"Basic :'
Age 0-10...S16.73 r•"`$0.00
'� Age - S.6G No crisis intervention,Minimal •
\laintenanccNot needed or cover '•°:
". I 1-14.••$18.50 CPA involvement one face-lo-
Rate ?ri Age 15-21...$19.75 under Medicaid.
. face visit with child per month.
ik.'
$15.51
55.05
y Minimal crisis intervention as Regularly Scheduled
1 $20.22 a $.66 ;0 needed,one face-to-face visit 1 S3.3`)
fs-za therapy up to 4
per month with child,2-3 4 .
hours/month. a
.... contacts per month f
I Y, $21 59 S.66 $17.19 $
------_
y
ri.ft" $18.88 $10.11
�' '``� •
Occasional crisis •interscntion as r Weekly scheduled
2 526.96 is S"66 needed,two face-to-face visits • therapy 5-8 hours a ir, $4.89
;•
i1": with child,2-3 contacts per month with 4 hours of a.1
Z group therapy..., , month ;
2 Y: $311.33 5.t,6 $20.56 -------
.,, Li'', i $2224 t d $15.16 Y FT.
9'. .
:1r9d; c t: Regularly scheduled
t Ongoing crisis intervention as 'r:'
•,; weekly,multiple
3 n.. 533.70 i. 5.66 :, needed,weekly face-to-face , 44
_ •sessions,can include $6.39
, ,1: visits with child.and intensive ;a more than I prison, 1'
'c coordination of multiple ` ? i.e.family therapy,for
-' S. servicrs. 9-12 hours/monthly. .4i
31/2 $37.06 5.66 :' $23.93
.
- --
$25.61 ,
air
4
\t -' Ongoing crisis inter ention as r'4 •.-.&• ,l
• needed,which includes high `'`i r-r;
Ft('(.f. S to 44 5.66 '' level of case management and r„ T Negotiated
7.Drop Donn �':..
Y ":.:';,1 CPA involvement with child and ;,
f j `1; ., provider and 2-3 face-to face
n• ,. contacts per week minimum f.
assessment/ ;: j, r
}•..
I.mergcncy ;G�y; $26.96 5.66 $18.88 a
Level Kate '",'„
S�i� .1 r. ,rt•
.k
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 14 day of (atxqui , 20121 ,
by and between the Board of County Commissioners of Weld County, on btltalf of the Weld
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Granquist, Derek and Jacqueline,whose address is
281 F.. Ilex Street, Milliken, CO 80543, hereinafter referred to as, "Contractor." This
Agreement covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as"Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department. and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014, to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspe
nded.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30)days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty (30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
I. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract I Revised 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.
1 I. To give the County Department two weeks notice, except in an emergency, to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or
other persons in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or
supervising agency.
CWS-7A Individual Provider Contract 2 Revised 6/2014
i. Any information received regarding a change of address of the parents or
guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of
1973, and the ADA of 1990, concerning discrimination on the basis of race, color,
sex, age, religion, political beliefs, national origin,or handicap, and to provide
confidentiality of information concerning the child in compliance with the Health
Insurance Portability and Accountability Act (HIPAA).
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family
Homes or Specialized Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal
personnel. The records shall document the type of care and the term during which
care is provided for each child. In addition, medical, educational, and progress
summary records shall be maintained for each child in accordance with Volume 7
requirements.
21. To maintain medical,dental and educational records for each child/youth and
supply updated information to the County Department.
22. To conform with and abide by all rules and regulations of the Colorado
Department of Human Services, the Colorado Department of Health Care Policy
and Financing(if appropriate), the State of Colorado and any applicable federal
laws and regulations, as such, which may be amended from time to time, and shall
be binding on Contractor and control any disputes in this Agreement.
23. To maintain a current license and maintain license requirements as specified
under State law and rule.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times during the term of this Agreement a liability insurance
policy of at least $25,000 for property damage liability, $150,000 for injury
and/or damage to any one person, and $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
CWS-7A Individual Provider Contract 3 Revised 6/2014
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records, documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection, review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
I. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
I I. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof
Ill. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
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:
l. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining,attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local) terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
`t County, on behalf of the Weld County Department
.ATTEST: duWl of Human Services
By: lait,00 Lima' By,:- ,
Deputy Clerk to the Board / rL
p Y Barbara Kirkmey2r, Pro-Yem
OCT 2 7 2014
CONTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT Granquist, Derek and Jacqueline
OF HUMAN SERVICES 281 E. Ilex Street
Milliken, CO 80543
By: By: '/ s. `7 y i/q/to,
my Di ector's desig e's) C ntractor's(or de gneeSignature
S. nature nd Date avate
By: ,_._ 8/14/14
Cont or s Tor des' nee's) Signature
culpiale
CWS•7A Individual Provider Contract 8 Re ised 6/2014
;16/1/-35-6
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 Granquist, Derek and Jacqueline, 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# 1631597. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing_ by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
CWS-7A Individual Provider Contract 10 Revised 6/2014
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
1. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on LIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
I I. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7A Individual Provider Contract 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
EXHIBIT B
NBC(NEEDS BASED CARE ASSESSMENT)
Answers to the following q uestions will determine the NBC Care Payment. For each question below please select the
h following seven (7)questions are mutually exclusive.
closest rating for this child. The o g
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 required uired to assist the child because of impairments beyond age Select One
P 9
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. Flow often are then. 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
J Presence of Psychiatric Symptoms/Conditions Select One
Enuresis/Encopresis Select One
Runaway Select One
I_ Sexual Offenses Select One
_ Inappropriate Sexual Behavior Select One
Disruptive Behavior Select One
__ Delinquent Behavior Select One
Depressive-like Behavior Select One
—
Medical Needs-(If condition is rated "severe",please Select One
ID
complete the Medically fragile NBC)
❑ Emancipation Select One
❑ Eating Problems Select One
• Boundary Issues Select One
I Requires Night Care Select One
❑ Education _ Select One
Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
I EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
wad . wr u F^�r
$12.14
County Basic 4 Age 0.10..$16.73 '°- $0.00
s: 5.66 No crisis intervention,Minimal 1
Maintenance Age II-14...$18.50 ' +L Not needed or cover
'-' Age 15-21...$19.75 CPA involvement,one face-to-
Rate ,: under Medicaid
face visit with child per month.
...., `
f� $15.51 '° ' $5.05
s yr
"".4'" : Minimal crisis intervention as Regularly Scheduled
v'5 $.66 ,J needed,one face-to-face visit $3.39
1 $20.22 sys- t therapy up to 4
^^. .., r..: per month with child,2-3 hours/month. 44-
sir,-
? contacts per month
Wis
'A er4A $23.59 '. $66 u $17.19 -------
.0104-
tias $18.88 $10.11 .,,
tr Occasional crisis intervention as Weekly scheduled ;
2 $26.96 ss1ii $.66 needed,two face-to-face visits � therapy 5-8 hours a V $4.89
with child,2.3 contacts per month with 4 hours of
group
month 8 P therapy. E-
2'A $30.33 '7 7*74 $66 $20,56 < �'�',
saY
w y'%+ $15.16 mrii its
tr.;, e, $22.24
' Regularly schedule frist
d
, , Ongoing crisis intervention as weekly,multiple 53,44.3
°�r '" needed,weekly face-to-face n
3 $33.70 s-u $66 ,gyp sessions,can include $6.39
visits with child,and intensive more than I person, '
s coordination of multiple $°+r=' i-e.family therapy,for s
it4, services. L.... 9.12 hours/monthly. ,a,
till
3 12 $37.06 „ $.66 $23.93
BI'm air
.-;13'i $25.61 "'z � „_-
m. Ongoing crisis intervention as
4SA - '] needed,which includes high
RCCF ILL $40.44 „i $66 � ,'., level of case management and 1:50' ------ Negotiated
Drop Down ;••-i, CPA involvement with child and
q. provider and 2-3 face-to face fits I
r t contacts per week minimum
v z -.-E -" �d r 3, sc`:.
fi
_.. , g
3�`a F, "
Assessment/ r ,,, , cs
Emergency ** $26.962 5.66 $18.88 - --------
Level Rate °..:.? 4-4
,t:„
4i
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 )"Aday of 0,.,LAA , 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 Irwin,Jeremiah and Kasi,whose address is 4544
Sunshine Circle,Loveland, CO 80538, hereinafter referred to as. "Contractor." This
Agreement covers all children placed by County with Contractor.
W ITNESSETH:
WHEREAS,the Colorado State Department of Human Services(hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
I lome/Emergency Shelter I tome(hereinafter referred to as"Facility"), and
WHEREAS,Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to.purchase foster care services,and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW,THEREFORE, in consideration of the mutual promises and covenants made
herein. County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014,to and until June 30, 2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30)days prior to the intended date of
termination. If notice is so given,this Agreement shall terminate upon the expiration
of thirty (30)days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first,and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF "IHE 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.
1 I. To give the County Department two weeks notice, except in an emergency, to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary.The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement. school officials, or
other persons in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or
supervising agency.
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 612014
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. 'I'o 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. '1'o inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy 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/'_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 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. I ime is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war. flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures,and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant,and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens,County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
I. Are not presently debarred, suspended, proposed for debarment.and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. !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
CWS-7A Individual Provider Contract 6 Rey iced 6'2014
•
public transactions(federal, state, and local)terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include.
but are not limited to. any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would he of no value to County,. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement. or other agreements between County and Contractor, or as a debt to
County. or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WI IEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County. on behalf of the Weld County Department
ATTEST: `'� ;� of Human Services
By: li1M lX i By." )ILl hk G %fit ti�
eputy Clerk to the Board Barbara Kirkmeyer, Pro—Tt
CONTRACTOR: OCT 2 7 2014
Approval as to Substance:
WELD COUNTY DEPARTMENT Irwin. Jeremiah and Kasi
OF HUMAN SERVICES 4544 Sunshine Circle
Loveland, CO 80538
By: By: 22 IL(
C t ty Dire tor's (o design 's) Contractor's (or designee's) Signature
tgt ature t Date and Date
By:
Cktractor's (or designee . )gnature
and Ala
CWS-7A Individual Provider Contract 8 Revised 6/2014
AOSI-3350
•
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Irwin,Jeremiah and Kasi, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
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
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 1D# 1644260. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
he release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays,deductibles, or services not covered by Medicaid, will need to be authorized. in
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 4111 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 62014
C. Placement service reimbursement shall he paid from the date of placement up to.
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. 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 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 document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors. and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
I. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis. if child is taking medications.
I I. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7A Individual Provider Contract II Revised 6/2014
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement.
theft, forgery, bribery, falsification or destruction of records. making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal. state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions(federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7)questions are mutually exclusive.
P1. How often does the child require transportation by the foster care provider for the following: Select One
Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc..as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. Flow much time is the provider required to intervene at home and%or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond aec Select One
appropriate needs with feeding,bathing.grooming,physical,and/or occupational therapy?
Al. How often is CPA/County case management required?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
T7. How often are therae •services needed to address child's individual needs per NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cruelty to Animals Select One
❑ Verbal or Physical Threatening Select One
❑ Destructive of Property;Fire Setting Select One
o Stealing Select One
❑ Self-injurious Behavior Select One
❑ Substance Abuse Select One
❑ Presence of Psychiatric Symptoms'Conditions Select One
❑ Enuresis/Encopresis Select One
❑ Runaway Select One
❑ Sexual Offenses Select One
Inappropriate Sexual Behavior Select One
Disruptive Behavior Select One
❑ Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
❑ Medical Needs-(If condition is rated"severe",please Select One
complete the Medically fragile NBC)
O Emancipation Select One
❑ Eating Problems Select One
Boundary Issues Select One
Requires Night Care Select One
❑ Education Select One
❑ Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
•r • EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
s4'T
t
,nr _. ..
512.14
Counts Basic rt-4 Age 0-Ill 81673 ery I1 51100 4' :
44�] 5 66 No crisis intervention,Minimal '4
Slamtenance '44 Age 1 l-14...51%.50 ,u- Not needed or corer -:1
$ ?� C PA im oh cmenl,one face-to r ; };
Rate 1 Age 15-21...519.75 '4 ` under Medicaid
i i thee.s kit with child per month I i'+
t I1 51551 a.3 ctil
— $5.05 '
ies s Minimal crisis intcnention as
I $20.22 5.66 ' Regularly Scheduled 5: e
pi needed-one tae to lam eisil { $1.1/
i'``, therapy up to 4
per month with child.2-3 &,
hours/month
contacts per month 4•4„, «s�
1 '/r 5?3.59 .7 5.66 O. $17.19 y"
i
�` $1%%% 510.11
^r Occasional crisis intenenuon as Weekly scheduled
2 . 526.96 ,1T- 5.66 1 needed.two file-to-face visits therapy 5-8 hours a $4.89
`9^ V . with child 22-3 contacts per .; month with 4 hours of Ic
rots therapy.ra �Ki*��+ month in group
r -.
2'G 530.:3 -4- 5.66 it $20.56 ".
t 522.24 513.16..f. Regularly scheduled :f
'1'4 .;1 Ongoing crisis inten ention as
ssttkly,multiple
t
3 $33.70 5.66 '�rc,'t needed,weekly face-to-thee F" sessions,can include 56.39
'• visits with child,and intensive more than I person,
Yeti -el coordination of multiple i.e. family therapy,for a
._ services '4'i 9-12 hours/monthly ,
"fi ink,
31/2 537.06 :241 5.66 •: $23.93 4
.; -f 525.61 ,7
gg
V Unguing crisis imen enlion as ,.'! :'
4 5WI' includesneeded,which includes high
RCCP' $40.44 5.66 level of casemanugement and aNLs
Negotiated
Drop Don g£ CPA involvement with child andPi
AO 4
pro-idcr and 2-3 lace to face
contacts per week minimum. its: 1,
5a
;;,..: .r4:S4t :ld-.?r-'„rf,11.::...._ . , - ._a _.r, . :,.. , -_. .,_._:.,..fiet i,.,,. ,..- �eci',,_,„_..s:. t.. . , it...,z ..,..srs:ti-
.5ssessment/ eli r + 3
Emergency $2(,96 f* $66 518.%% 1 r 4
Level Rate tv4vk
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 (8 day ofl I k , 201,
by and between the Board of County Commissioners of Weld County, on beat-of the Wed
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Kusluski, Gary and Selinda, whose address is 4457
Firehawk Ct., Windsor, CO 80550, hereinafter referred to as, "Contractor." This Agreement
covers all children placed by County with Contractor.
W IlNESSETH:
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, TIIEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014,to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty (30)days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty (30)days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease: however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
I. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
C'WS-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.
I I. To give the County Department two weeks notice, except in an emergency, to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or
other persons in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or
supervising agency.
C'WS-7A Individual Provider Contract 2 Revised 6/2014
i. Any information received regarding a change of address of the parents or
guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of
1973.and the ADA of 1990, concerning discrimination on the basis of race, color.
sex, age, religion, political beliefs, national origin, or handicap, and to provide
confidentiality of information concerning the child in compliance with the Health
Insurance Portability and Accountability Act(HIPAA).
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family
Homes or Specialized Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal
personnel. The records shall document the type of care and the term during which
care is provided for each child. In addition, medical,educational, and progress
summary records shall be maintained for each child in accordance with Volume 7
requirements.
21. To maintain medical,dental and educational records for each child/youth and
supply updated information to the County Department.
22. To confirm 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
.w.. ..�.*,..t„y.r .:.a ....:,!;.w.. ....,,<, yw.S.. ...,,,w�+..,a ----,n-..e_.....,....,...... ......... ......... �cw.--r...�... ,..-............,.... i.r..............-.........-.. ......_..................- --._.........-..
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death.
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby. or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records, documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection, review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
I. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
I. 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.
[H. 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 he 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. I lave not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions(federal, state, and local) terminated for cause or default.
N. In addition to terminating this Agreement. in accordance with the provisions of
Section I.. above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include.
but are not limited to, any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission.
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no pan 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
r Contractor, within five (5)calendar days after being served with a summons.
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors.
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WI IEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: W J ;zi of Human Services
/yr� Q � fo-naBy: UA l.(,/� By GLi h.Ltu ', t S f.1/1-t`[1/v
eputy Clerk to the Board / /
Barbara Kirkmeyer, Pro-Tem
CONTRACTOR: OCT 2 7 C:4
Approval as to Substance:
WELD COUNTY DEPARTMENT Kusluski, Gary and Selinda
OF HUMAN SERVICES 4457 Firehawk Ct.
Windsor, CO 80550
X11
By: By. Y,
; �� Llk L.0
inty Di ector'sl r desi nee's) Contractor's (or designee's) Signature
Si nature nd Dat and Date
By: 6� 4f / 'f '/fly
ontractitt's(or designee's) Signature 2'
and Date
CWS-7A Individual Provider Contract 8 Revised
6/2014
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
C:WS-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 Kusluski,Gary and Selinda, 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# 1586228. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays,deductibles.or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25)calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall he paid from the date of placement up to.
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of I luman 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
.a+A81}.11YAl1:UM4+,:pi'G:.x....•,,:.'i101�UPw:�eJl:k't'!11'2t::...SN•"�•+ •wiwiL::Y", Vw+.M�:s-�..`xY`.Yw-a.: a a:.'�:�.Y AI '.1Y4tl['k'Ya.,�:M?+:�1!FbIbY.Fc,•• .....
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors,and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
1. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain,access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis. if child is taking medications.
I I. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred,suspended. proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7A Individual Provider Contract 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.
t'W S-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC(NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven(7)questions are mutually exclusive.
PI. I low often does the child require transportation by the foster care provider for the following: Select One
Therapy; Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. Flow much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. l low often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and'or activities and'or crisis management?
P5. flow much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing,grooming,physical,and or occupational therapy?
Al. I low often is CPA/County case management required?(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. I low 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'I hreatening 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/Enco_presis Select One
❑ Runaway Select One
❑ Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
17_ Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
❑ Medical Needs-t I f condition is rated"severe",please Select One
complete the Medically fragile NBC)
Emancipation Select One
Eating Problems Select One
Boundary Issues Select One
Requires Night Care Select One
Education Select One
❑ Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2_014
EXHIBIT(
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
7'-'''7.
�.F , +•i x 5•°r :'r., .!.'•,.;:. N+'5�11•i�} ,'f, via:-i--f ter..`?:.'.; '4
4. ,!,
. r ; t2 =�) Iy6,- r s 't ;ieft``L5 F..• i++t,tlr,tr-„E' t:1•."t...,'.3i, St'`t' Rr, ,
1' 1 ` �fS,t? t�'t'4 it • i,, .,3.7Lr.3 1t" ' 4• ?,;: • its z
1'a46,{.L‘ �j+,'.. ehco,,,i,t 11:7; .1:(41..11,4"l. e.=X 1 ..`,1 r .a. ,.sl'<II'w:, 1ail:: -s
4 rw a.✓'M�. J r ..fj 1!$.a.. i_-.. a +. ..-:'Y',:1... .. _ ...13 yyJ S' `f f {{.
('ounty Basic1ge 0-10...516.73 � ' $12.14 $0.00 n 4
Maintenance Age 1 1-14...518.50 5.66 1x.,%; No crisis into+vention.hlinima) Not needed or cover
`'-`: CPA involvement,one face-to- ,
Rate .. Age 15-21._$19.75 tinder Medicaid.
r r face visit with child per month. ,xx
_____.
_ A t`a
,.._... 515.51 .,
g $5.05
:,.4 Minimal crisis intervention as Regularly Scheduled
I x 520.2' 5.66 r4': needed.one face-to-face visit ►_,`y�."3�q` $' '`�
a ' therapy up to 4 yi
per month with child.2-3 hours/month. K;4
iimaicontacts per month ..,1
-.:3
s
I 'A °' $13 59 5.66 1;' ,' 517.19 ( ,
re's
518,88 $10.11 ,1f•
+< ,r" Occasional crisis intervention as Weekly scheduled
-,3)4
4.
._. 526.x; 5.66 needed.two face-to-face visits - therapy 5-8 hours a 's S I.R')
• p.,,.:,� with child,_2.3 contacts per month with 4 hours of
+ month group therapy.
2'/, 5;11.33 ' 5.66 $20.56 ;K
v
ile'1i ':Ll.
;' 522.24 $15.16
}'`'' s.,•" Regularly scheduled v.
6 Ongoing crisis intervention as
weekly,multiple •~I
3 $33.-0 566 needed.weekly face-to-face r= sessions.can include 5;.• $6.39
visits with child,and intensive r' . '{
r` '° more than I person. r
�". ' coordination of multiple
fit: :'' , i.e,family therapy,for
7 = services. 9-12 hours/monthly.
Y(r� ,
$23.93 --------
3
1/2 $;7.116 5.66 .
ki, 7
.fi l{all525.61 R .
rj'' Ongoing crisis intervention as
4 t ' netided.which includes high ,,-.-e,
R(CF ,'•, $40.44 °•;g $.66 ? Negotiated
s level of case management and
Drop Down ," • ,-0,4' �,r-? CPA involvement with child and
Wt ' provider and 2-3 lace-to face %:.•
'
tt�� I. t.: contacts per week minimum.
lvsessmcnt/
F:+nerRency :: $26.96
5.66 i $18.I18 t '*
Level Rate ,.i,' r
Vr
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 day of Od , 20 i ) ,tber
by and between the Board of County Commissioners of Weld County, on behalf of the Weld
County Department of Human Services, whose address is P.O. Box A,Greeley, CO, 80632,
hereinafter referred to as, "County,"and Maronek,Dennis and Patricia, whose address is 2929
56th Ave, Greeley, CO 80634, hereinafter referred to as, "Contractor." This Agreement covers
all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as"Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
1. TERM:
A. The term of this Agreement shall be from July 1, 2014,to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30)days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30) days, or until the eligible 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. 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 F
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. 1
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 Man
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services,the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
ii
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 pa ent to Contractor until the necessary services or corrections in
PYm
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
Ii
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,���`` , ��,// County,on behalf of the Weld County Department
ATTEST: `id�st/ .JC,[to•ede of Human Services
By: Cfrlia IS La
P- u Clerk to th- :o "
p ty5� Barbara Kirk e er, Pr6—Tem
1b61 tt �.: �1 y
X46(_ '
TRACTOR: OCT 2 7 2014
Approval as to Substance:
WELD COUNTY DEPART~+ , ' aronek, Dennis and Patricia
OF HUMAN SERVICES 2929 56th Ave
Greeley, CO 80634
By: By:
o my Dir ctor's desig e's) Contractor's(or designee s) Signature
Si ature d Date and ate - /S- ,9
/�(IYIJ 10-By: Contractor's�(o design 's) Signature
and Date 57_/5-. �y
CWS-7A Individual Provider Contract 8 Revised 6/2014
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 Maronek, Dennis and Patricia, 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 I
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# 1520627. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
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
reimbursihkement 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 I
i
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 l4 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 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
' EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7) questions are mutually exclusive.
P1. How often does the child require transportation by the foster care provider for the following: Select One
Therapy;Medical Treatment; Family Visitation;Extraordinary Educational Needs;etc.,as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
PS. How much time is the provider required to assist the child because of impairments beyond aae Select One
appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy?
Al. How often is CPA/County case management required?(Does not include therapy) Select One
""Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
Ti. How often are 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:
❑ ggression/Cruelty to Animals Select One
❑ Verbal or Physical Threatening Select One i
Destructive of Property/Fire Setting Select One
Stealing Select One i
❑ Self-injurious Behavior Select One
tn,, 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
ZJ Eating Problems Select One
Boundary Issues Select One
Requires Night Care Select One
Education Select One
ZJ 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
in,..,
ta�� (Effective 7/01/2014) pp
�5 •.S -,.tf * I"�nx�. ° :fa. yam; I 11 ,�t t1 I d x° ,.•_, Y17 , ''a.I;4;,11 CR 1: ,.-,!)I
x vl Ji" • •P''
s;�°. • , i l6V oY • • ' yu 4'U7 .I}R4r� r' tkls v .1.�+ ...''''•,•''''
,.,: li: .
`"°.irv.%r , f :taG�ht µt4 yam.;
' 2t#',I °,.'fl '1J 1!4•::).tllt•' + y3 1 , k ` Q it 14''-"•!i:W. , 1 .,
'r. $12.14
County Basic ht. Age 0-10...$16.73 ₹� $0.00 .
$.66 • No crisis intervention,Minimal ' ..
•Maintenance Age l 1-14_.$18.50 Not needed or cover
face-to-
Rate '--.P: Age 15-21...$19.75 r-? - CPA involvement,one under Medicaid.
t 'a face visit with child per month.
IC
_✓ '"^ .:
:a S15.51
14F , $5.05
. J Minimal crisis intervention as Regularly Scheduled
1 $20.22 $.66 :a needed,one face-to-face visit therapy up to 4 53.39
Per month with child,2-3 - ', ''..:
- hours/month.
contacts per month - ,
1 %, $23.59 $.66 $17.19
.' ° $18.88 $10.11
j e
� , Occasional crisis intervention as Weekly scheduled
2 $26.96 $.66 'V' needed,two face-to-face visits therapy 5-8 hours a $4.89
with child,2-3 contacts per month with 4 hours of . .--
month group therapy.
•
2 %: $30.33 $.66 $20.56
q $22.24 $15.16
Regularly scheduled
Ongoing crisis intervention as weekly,multiple 1.1
needed,weekly face-to-fact
3 $33.70 $,66 s� sessions,can include 5639
visits with child,and intensive more than 1 person,
coordination of multiple i.e. family therapy,for t^
services.
r 9-12 hours/monthly.
41. It 31/2 ,tj $37.06 $.66 r++. $23.93 ;, ---------
•
$25.61
Ongoing crisis intervention as -m.
4 needed,which includes high °"
RCCF $40.44 $.66 level of case management and Negotiated
Drop Down xi,` CPA involvement with child and
provider and 2-3 face-to face
contacts per week minimum.
>a.
F,,
Assessment/ 5s
Emergency114 I $26.96 is 5.66 , . $18.88 's, ----------- ₹°.-
Level Rate ti• ..
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this I Li day of 20 1q ,
by and between the Board of County Commissioners of Weld County, on beha of the Weld
County Department of Human Services, whose address is P.O. Box A,Greeley, CO, 80632,
hereinafter referred to as, "County," and Miller,Linda,whose address is 2034 Birch Ave,
Greeley, CO 80631, hereinafter referred to as, "Contractor." This Agreement covers all children
placed by County with Contractor.
WITNESSETH: 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 be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, to and until June 30, 2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 1 Revised 6/2014
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.
1 I. To give the County Department two weeks notice, except in an emergency, to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or
other persons in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or
supervising agency.
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 forpropertydama a liability, $150,000 for injury
po cy g Y J
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 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:
L Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain,or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state,or local)with commission of any of the offenses
enumerated in paragraph(B)above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local)terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: d ;eik, of Human Services
V
By: i� 1.��l, �, ' �'``'y: ' LA kfu / kiiiiLJ t_,�
Deputy Clerk to e 'r< yay�. tarbara Kirkm yer, Proem
AM1 O lil
ONTRACTOR: OCT 7 2014
Approval as to Substanc
WELD COUNTYDEPA`' a Miller, Linda
OF HUMAN SERVICES 2034 Birch Ave
Greeley,CO 80631
By: a �L. �� ��l..l; By: $,_ I i 13(1
C ty Di ctor's rr: desig , e's) Contractor's(or designee's) Signature
ig ature . d Date 1 and Date
By:
Contractor's (or designee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 612014
A014-3350
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Miller, Linda, hereinafter referred to as, "Contractor."
GENERAL PROVISIONS
. 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# 1628214. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided,the County reserves the right to
deny payment.
B. Be submitted by the 4`h of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 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:
I. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
I I. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
CWS-7A Individual Provider Contract I I Revised 6/2014
..
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B)above.
D. 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
l sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy?
Al. How often is CPA/County case management required?(Does not include therapy) Select One
'"Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
TI. How often are thera. services needed to address child's individual needs 'Cr NBC assessment? Select One •
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cruelty to Animals Select One
-Li Verbal or Physical Threatening Select One
Destructive of Property/Fire Setting Select One
Stealing Select One
Self-injurious Behavior Select One
LJ Substance Abuse Select One
Presence of Psychiatric Symptoms/Conditions Select One
_ Enuresis/Encopresis Select One
❑ Runaway Select One
u Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One
I Disruptive Behavior Select One '
U Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
Medical Needs-(If condition is rated"severe",please Select One
D complete the Medically fragile NBC)
❑ Emancipation Select One
Eating Problems Select One
Boundary Issues Select One
_e]
Requires Night Care Select One
Education Select One
LJ 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)
-.. _ L
m '' . .
" $12.14
County Basic Age 0-10...$16.73 ,E $0.00 >,
$.66 `- No crisis intervention,Minimal ,
;
Maintenance " ' Age 11-14..$18.50 ' c- Not needed or cover w. , —
Rate '' Age 15-21...$19.75 CPA involvement,one face-to- under Medicaid.
35i/
,,,._ face visit with child per month.
B,'as $15.51 ? $5.05
; '.. Minimal crisis intervention as ' Regularly Scheduled
1 x� $20.22 'tl $.66 needed,one face-to-face visit $3.39
- "'_ therapy up to 4
per month with child,2-3 • hours/month.
contacts per month 'i
I X4
$23,59 $.66 $1719 — t. --•--•--IfiMIN
,= tom. $18.88 2", $10.11
" Occasional crisis intervention as d'a Weekly scheduled 44
2 $26.96 ,.c $.66 needed,two face-to-face visits therapy 5-8 hours a - $4.89
e ,,, with child
month with 4 hours of ""
.2-3 contacts per
r month 1: group therapy.
z.fkl
2 'A :"c $30.33 $.66 $20.56 j,,!, -------- r
" " ; $22.24 j-'_ $15.16 w"a
'A:: Regularly scheduled k'',
-s �' Ongoing crisis intervention as 5:s
weekly.multiple
3 ..X $33.70 $.66 needed,weekly face-to-face sessions,can include $6.39
' visits with child,and intensive •^� '"" coordination of multiple , more than I person,?
11.-; l
p ,;, i.e.family therapy, for 1_-
11,112 services. 9-12 hours/monthly.
3 1/2 $37.06 $.66 $23.93 -.._------
$25.61
1,41
-i:, Ongoing crisis intervention as ,s,
4 . •_. needed,which includes high
RCCF p,,.„i $40.44 1 $.66 tic54, level of case management and y;t,, Negotiated
Drop Down : . CPA involvement with child and _..a
`')° Will provider and 2-3 face-to face
te:
max. contacts per week minimum. at 7'rx
f
Assessment/ ""'
Emergency a-s $26.96 -- $.66 $18.88
Level Rate -ea
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 this2a day oft('jt hi , 20 RI,
by and between the Board of County Commissioners of Weld County, on behalf of the Weld
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Miller, Pamela, whose address is 5151 W 29th Street,
Unit 2004, Greeley, CO 80634, hereinafter referred to as. "Contractor." This Agreement covers
all children placed by County with Contractor.
W ITNESSETH:
WHEREAS. the Colorado State Department of Human Services (hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department. and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, to and until June 30, 2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty (30)days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty (30)days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not he released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
I. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
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 ? Revised 6!2014
i. Any information received regarding a change of address of the parents or
s.tuardians.
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 Yp 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 he by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
I I. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. "lo assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall he released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement. Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement. Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports. on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God. fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures. and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further. Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
I. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction:
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements. or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal. state,or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. I lave not within a three-year period preceding this Agreement. had one or more
CW S-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 he
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons.
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST:
�/ of Ilumman Services
a1 By: ;I t-CL1 _ �t.C` 13yF1 .(, llL ,' hk/i L
)eputy Clerk to �''. �-�� / Barbara Kirkdeyer, Pr
ONTRACTOR: OCT 2 7 2014
.u,O 1/49 f;
Approval as to Substan e , t.R
WELD COUNTY DEP. E u illcr, Pamela
OF HUMAN SERVIC , 1 151 W 29th Street, Unit 2004
t1I0 , Greeley, CO 80634
By: . By:40AnLnaAS,Q.
n' s/ 14-
Co y Direct Ws(or d signee' Contractor's(or designee's) Signature
Sin ure an ate and Date
By:
Contractor's(or designee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
la ON 3551)
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement." hereinafter
referred to as, "County," and Miller, Pamela, hereinafter referred to as, "Contractor."
GENERAL PROVISIONS
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# 1587465. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 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;
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 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 612014
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy. reorganizations and/or foreclosure.
CONTRACTOR SHALL:
I. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate,and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain.access and review information weekly on F1DOS.
8. Read. be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain;update information in the foster child's binder.The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
I0. Maintain/update medication logs on a daily basis. if child is taking medications.
I I. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Arc not presently debarred, suspended. proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining,attempting to obtain, or performing
a public(federal, state, or local)transaction or contract under a public transaction;
CWS-7A Individual Provider Contract I I Revised 6 2014
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property:
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state,or local) with commission of any of the offenses
enumerated in paragraph (B)above.
D. 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 V11 and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6'2014
EXIIIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven(7)questions are mutually exclusive.
P1. How often does the child require transportation by the foster care provider for the following: Select One
Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and'or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
PS. How much time is the provider required to assist the child because of impairments beyond are Select One
appropriate needs with feeding,bathing.grooming,physical,and/or occupational therapy?
Al. How often is CPA/County case management required'?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
T7. How often are thera. services needed to address child's individual needs .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 Threateninj 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
❑ Inapproyriate Sexual Behavior Select One
o Disruptive Behavior Select One
❑ Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
O 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 Carc 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)
ter: + .7<.. :..► :,� �.,� y v v. .a r.�' s
: - .i' i`ti
�,!"�vi}i� •c. ',...y,.', !t `t '�'S �,r 1Q
,�'l`] d.1�1 r � .• .ti [ .L � >( �'e lY� GP r.pd,'. 4• ,•� �` � •• � - • �. aS
,.ti;:' :.r..._.tr_ �.4:�•:�. :vx:c2 Z ` `• -1.4;0.1s•-0-1.:.i. _f'il,...`- ,.�t:.'..•
tr 3 7�6T 1r '♦',M{(J'' ••�` '�� �+R�*J�i�` 'fJ d''111'''1:,:-.$,',„,.si. '. ...v•:*4:4..7 {,}j" �� r } •�r` •i', y+ +'
,i0"r�: a %.Srf.. •.{,6,'i ',6r � ��• x sit . r.5'� 9„�
, :, , +• .:t�K.ilCu�nti:h ,d" e/aSC 1 !'... .. . •rt4.. r - ":N;uMii,n: `' Lv.:.:..+x.
f':: 512.14
County Basic Ageo-10...S16.73 ,' SO.otl
$.66 No ensis Intenennon,Minimal •
Maintenance Age I I-14...SI8.50 _ ,.,- Not needed or cover
•• CPA imohcment.one face-to- r
Rate Age I5-21...S19.75 under Medicaid. r4-
Y. 't:- lace visitslilt child per month.
-- - - " Sri -
z $5.05 ,Al
i `: V.`s. Minimal crisis inters ention as `' '
I " '.' 520.22 5.66 Regularly Scheduled ty" Si ;v
n needed.one thee-to-face visit I, • therapy up l0 4
�xf per month s oh child.2-3 hours/month.
4,-': •,.a •. contacts per month
r,,::� .;P
I ''4 52_3.59 t ; $.66 tt: 517 I9 y,Lff ------....-
:ti SI%.RR .' $10,11
fr
� sch
eduled h Wee
kly sceue
= u.:< "r Occasional crisis inlcnrntion as : `•a
2 526.96 "� S.66 ` , therapy 5-8 hours a 54.89
F {y:%, needed.two face-to-face visits '
l with child.2-3 contacts per month with 4 hours of •
r,` group therapy.
,. month
2 Y, 5±0.3; 5.66 $211.56 ......... ;
7`r.S :• 522.2; `�?:
515.16
$,: _it: 4 Regularly scheduled '
{. Ongoing crisis intervention;t,. '%0 weekly.multiple
,{ needed,wcckl face-to-face
3 $?3.7U 5.66 > ? sessions,wn include r' 56 39
a ' visits with child,and intensive
%: ,,._. nxirc than 1 person.
« '<.., coordination of multiple i.e.family therapy,for
ilLki-
rt.`.: :: sen ices, 9-12 hours monthly. ;
3In 5?7.0 `: S-66 523.93 -- ��
525.61 •
:�'= I.:•: Ongoing crisis intenrntion as .,"
r
4 t: '' ' needed,shish includes high
R( ('I $40.4.1 !14-. 5.66pt '-.. Negotiated
`� level of case management and
10
Drop Dots n l,,r; A.,fir:
('PA invnlvcmcnt with child and -;�.
?I ,-`•' provider and 2-3 face-to face P.
r is
rt ,,, contacts per seek minimum. 5
t � r. r`33''i ` f ra: f5i {�A yam.}s y {{� , r may;.;
.. ssc,
.,sseccment/ s
.
Emergency `"
526.96 f-FI,'' $.66 SIX 88 {'
Level Rate ' Jt;
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT f-n./{
THIS AGREEMENT is made and entered into this/+ 7 day of0d (,,e , 20 P 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 Pluma, Mike and Annette, whose address is PO Box
34, Kersey, CO 80644, hereinafter referred to as, "Contractor." This Agreement covers all
children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, to and until June 30, 2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual
Provider Contract 1
Revised 6/2014
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.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
1. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local) terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST:da , ;4 of Human Services
By: Ita I.& By: 74t
Deputy Clerk to the Board 'Barbara Kirkmeyef, Pro-Tel
CONTRACTOR: OCT 2 7 2014
Approval as to Substance:
WELD COUNTY DEPARTMENT Pluma, Mike and Annette
OF HUMAN SERVICES PO Box 34
Kersey, CO 80644 By; By: /die n ir-r`/
aAV
my Dir ctor's( designe 's) Contractor's(or desi e's) Signature
ature a d Date and to
By:
o ractor's(or designee's) Signature
an Date
CWS-7A Individual Provider Contract 8 Revised 6/20 I4
AO/103g)
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Pluma, Mike and Annette, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit 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# 35126. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance fonn accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
CWS-7A Individual Provider Contract 10 Revised 6/2014
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
1. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7A Individual Provider Contract 11 Revised 6/2014
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7)questions are mutually exclusive.
Pl. How often does the child require transportation by the foster care provider for the following: Select One
Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing,grooming,physical, and/or occupational therapy?
Al. How often is CPA/County case management required?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
TI. How often are theras services needed to address child's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cntelty 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
I ❑ Presence of Psychiatric Symptoms/Conditions Select One
ym p
O Enuresis/Encopresis Select One
❑ Runaway Select One
❑ Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One I
❑ Disruptive Behavior Select One
❑ 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)
❑ 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
I
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014) ti:11: 0 ;• ; r 11NI 41 . v r ,tiilt!Am Kw Al 15 ). ;I t~it':na t .: n t 1:•.{irt .,
`M.Y'.1 �ftr'dt Ali Yxlt� >yx�4 z r ,�Pye +tt�`ft.7. '-f :1.A;?; t • :1 • ,1 :-
raM fe
� f
*T 3"r). .(, h Y kq.r R +y v3n N -r..�.....u..,. ..i...........
•
.• ...'h ....... &'iFa �idv..._ 1..as-x .. .,.y....- 2 rr.>iis>Pi_u... w..xJ, .�.i.:.... .. /.
512.14
County Basic Age 0-10...$16.73 •+""�- 50.00
Maintenance - Age 11-14...$18.50 •u? 5.66 j,- No crisis intervention,Minimal Not needed or cover
i��` CPA involvement,one face to
Rate Age 15-21...$19.75 ',y, under Medicaid.
.. face visit with child per month. ,,,g'
i k v:4
_ $15.51 ' , $5.05
r}k Minimal crisis intervention as Regularly Scheduled
1 °f. $20.22 •"• $.66 needed,one face-to-face visit $3.39
�-,-` therapy up to 4
per month with child,2-3 hours/month.
If contacts per month
1 1/2 $23.59 I $.66fl $17.19
$18.88 510.11
Occasional crisis intervention as Weekly scheduled
2 fp, 526.96 $.66 needed,two face-to-face visits therapy 5-8 hours a 54.89
with child,2-3 contacts per month with 4 hours of
month group therapy.
2 %: 1 $30.33 $.66 t $20.56
$22.24 515.16
#4 Regularly scheduled
4`g Ongoing crisis intervention as weekly,multiple
3 $33.70 $.66 needed,weekly face-to-face sessions,can include $639
visits with child,and intensive more than I person,
coordination of multiple i.e. family therapy,for •
x. services. 9-12 hours/monthly.
31/2 15;e $37.06 • 5.66 523.93
'' * 525.61
!is,'
S"' Ongoing crisis intervention as
4 4'' cc needed,which includes high
RCCF I0-- $40.44 $.66 i level of case management and ' Negotiated
Drop Down CPA involvement with child and •
provider and 2-3 face-to face
..14 contacts per week minimum.
I fir; i' A. ..
Assessment/ ,
Emergency t@, 526.96 5.66 $18.88
31
Level Rate "'
, iliti i
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 21 day of ONO- , 20 114,
by and between the Board of County Commissioners of Weld County, on behalf of the Weld
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Risler, Jason and Hadley-Risler, Tamara, whose
address is 3717 Soderburg Dr, Fort Collins, CO 80526, hereinafter referred to as,
"Contractor." This Agreement covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, to and until June 30, 2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty (30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 1 Revised 6/2014
2. To safely provide the 24-hour physical care and supervision of each child until
removed or until the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and
participate in the development of the Family Service Plans for children in
placement, including visits with their parents, siblings, and relatives, or transition
to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human
Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the
Department.
10. To allow representatives of the County Department to visit the foster home and to
see the child at any reasonable time.
11. To give the County Department two weeks notice, except in an emergency, to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f Any conflict the child may have with law enforcement, school officials, or
other persons in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or
supervising agency.
CWS-7A Individual Provider Contract 2 Revised 6/2014
i. Any information received regarding a change of address of the parents or
guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of
1973, and the ADA of 1990, concerning discrimination on the basis of race, color,
sex, age, religion, political beliefs, national origin, or handicap, and to provide
confidentiality of information concerning the child in compliance with the Health
Insurance Portability and Accountability Act (HIPAA).
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family
Homes or Specialized Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal
personnel. The records shall document the type of care and the term during which
care is provided for each child. In addition, medical, educational, and progress
summary records shall be maintained for each child in accordance with Volume 7
requirements.
21. To maintain medical, dental and educational records for each child/youth and
supply updated information to the County Department.
22. To conform with and abide by all rules and regulations of the Colorado
Department of Human Services, the Colorado Department of Health Care Policy
and Financing (if appropriate), the State of Colorado and any applicable federal
laws and regulations, as such, which may be amended from time to time, and shall
be binding on Contractor and control any disputes in this Agreement.
23. To maintain a current license and maintain license requirements as specified
under State law and rule.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times during the term of this Agreement a liability insurance
policy of at least $25,000 for property damage liability, $150,000 for injury
and/or damage to any one person, and $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
CWS-7A Individual Provider Contract 3 Revised 6/2014
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records, documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection, review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
1. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local) terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
1. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term"litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: U.ttrAH/ W �� of Human Services
/ -
�/y / _7, 1".e C.:3 �"fi„�/ , t 7 4 C i-/C,{ Cdr t�
By: bep tti l 'L .
eputy Clerk to the arty ‘ `,''Barbara Kirkmeyer, Pro—Tern
(0.'1/ .�y l OCT 8 7 2014
• a 1 's l4?TRACTOR:
Approval as to Substance: \\(,;‘,- t, .. ' �O1 b,-
WELD COUNTY DEPARTMCNT';—" 51,4er, Jason and Hadley-Risler, Tamara
OF HUMAN SERVICES 3717 Soderburg Dr
Fort Collins, CO 80526
a
By:
BY It 4 ` 2 r& -�itcrd,Le el
ctor's ( esigl e's) Contractor's (or design e's) Signaturelad Date ' and D e By ntraetor's (or des'gnee' ) Si4nature
and Date
C'WS-7A Individual Provider Contract 8 Revised 6/2014
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 Hadley-Risler, Tamara and Risler, Jason, 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# 1631808. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 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
a duty of care that did not previously exist with respect to any
be deemed to have created
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
CWS-7A Individual Provider Contract 10 Revised 6/2014
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
1. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7A Individual Provider Contract 11 Revised 6/2014
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7)questions are mutually exclusive.
Pt. How often does the child require transportation by the foster care provider for the following: Select One
Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy?
Al. How often is CPA/County case management required? (Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
Ti. How often are theme services needed to address child's individual needs •er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
U 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
ICI
complete the Medically fragile NBC)
❑ Emancipation Select One
Eating Problems Select One
Boundary Issues Select One
Requires Night Care Select One
Education Select One
Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
fW� 4 p f
� {'4:116 yy � K` t t )� Nl wpnai a.y4atie,° „asi/tF�f;/w
*'§� �I.,I�d Y� .. •`�' � 4II. , ` > t. JIriVip4N,y c iii iDtr ".`e 4 -i -'-
r a, i �, r yt j? 4 - s I 3,R4
5sf 1
ye( � YT * . i Daily. + T,
� �+M, — . . -..-_i.'` 51214 ..
County Basic t Age 0-10...$16.73 $0.00
No crisis intervention,Minimal r
Maintenance Age 11-14...518.50 Not needed or cover ---------
CPA involvement,one face-to- .
Rate Age 15-21...519.75 84under Medicaid. c
Szi ,yam face visit with child per month. e
-; kr S15.51 SS.o5
w.:s.
,. Minimal crisis intervention as Regularly Scheduled
1 $20.22 5.66 needed,one face-to-face visit a 53.39
r therapy upto4 +i
a per month with child,2-3 hours/month.
contacts per month ,
1 %2 ' $23.59 'xt 5.66 517.19
a fy 518.88 510.11
" Weekly scheduled
' Occasional crisis intervention as ; i
2 .'.n: $26.96 5.66 needed,two face-to-face visits therapy 5-8 hours a 54.89
with child,2-3 contacts per 4 month with 4 hours of
month , group therapy.
2 '/2 ,"- 530.33 $.66 p 520.5644 444 , ,
-r-
- 515.16
_- •• S2224
a` Regularly scheduled
_ 44.'" Ongoing crisis intervention as weekly,multiple
3 $33.70 $.66 needed,weekly face-to-face sessions,can include 56.39
visits with child,and intensive more than I person,
,i coordination of multiple i.e. family therapy,for
services. 9-12 hours/monthly.
31/2 '" $37.06 ,1 5.66 r`x 523.93
, 525.61 ae.
' Ongoing crisis intervention as '',
4 + needed,which includes high
RCCF $40.44 =42 5.66 level of case management and 'c.. Negotiated
Drop Down 4,. ': CPA involvement with child and 4
-- provider and 2-3 face-to face 1
,' ,,g contacts per week minimum.
474=44+;cr<t * - .a . a .; .. _
O I
Assessment/ ., v 4'u,.
Emergency $26.96 5.661 $18.88 '&
n
Level Rate
Exhibit C to the Additional Provisions 14 Revised 6/2014
I
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENTfn
f�� 1l
THIS AGREEMENT is made and entered into this day of O4f(/I , 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 Serna, Leo and Carol,whose address is 1020
Cottonwood Ave, Windsor, CO 80550, hereinafter referred to as, "Contractor." This
Agreement covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to,purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, to and until June 30, 2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 1 Revised 6/2014
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. My pertinent discussion with parents or guardians about the child or
supervising agency.
CWS-7A Individual Provider Contract 2 Revised 6/2014
i. Any information received regarding a change of address of the parents or
guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of
1973, and the ADA of 1990, concerning discrimination on the basis of race, color,
sex, age, religion, political beliefs,national origin, or handicap, and to provide
confidentiality of information concerning the child in compliance with the Health
Insurance Portability and Accountability Act(HIPAA).
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family
Homes or Specialized Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal
personnel. The records shall document the type of care and the term during which
care is provided for each child. In addition, medical, educational, and progress
summary records shall be maintained for each child in accordance with Volume 7
requirements.
21. To maintain medical, dental and educational records for each child/youth and
supply updated information to the County Department.
22. To conform with and abide by all rules and regulations of the Colorado
Department of Human Services, the Colorado Department of Health Care Policy
and Financing (if appropriate), the State of Colorado and any applicable federal
laws and regulations, as such, which may be amended from time to time, and shall
be binding on Contractor and control any disputes in this Agreement.
23. To maintain a current license and maintain license requirements as specified
under State law and rule.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times during the term of this Agreement a liability insurance
policy of at least$25,000 for property damage liability, $150,000 for injury
and/or damage to any one person, and $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
CWS-7A Individual Provider Contract 3 Revised 6/2014
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records, documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection, review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement,parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services,the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies,procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
1. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local)terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
1. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the County
Director. The term"litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
Sep 05 14 09:06a Owner 970-460-0181 p.2
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
der:4V ,/ ; County,on behalf of the Weld County Department ATTEST: 4.14 O ti of Human Services
�.r /
•
Bye- 1. L i �ilL :, . . 777,, ;, / yt_AL
Deputy Clerk to 1 Sktp:', .i+�►y ��` Barbara Kirkmey rPro—Tkm
It � ,� 0CT 2 7 2014
•tNTRACTOR:
Approval as to Substanc:• r Vire 1
WELD COUNTY DEPA•�4` ��n erna, Leo and Carol
OF HUMAN SERVICES - - 1020 Cottonwood Ave
Windsor, CO 80550
By; By: _ 8`i x7 ft
o my D ector'sl( rdes nee's) Contractor's(or designee's) Signature
i nature nd Date, and Date
By: CC OL ±2T] )I'(
Contractor's(or designee's)Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
al0 3-35`
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement,"hereinafter
referred to as, "County," and Serna, Leo and Carol, hereinafter referred to as, "Contractor."
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit 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# 1597453. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4`h of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
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 Provider Contract 11 Revised 6/2014
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph(B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7)questions are mutually exclusive.
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?
I
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy?
Al. How often is CPA/County case management required?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
T1.How often are thera, services needed to address child's individual needs •er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
U Aggression/Cruelty to Animals Select One
U Verbal or Physical Threatening Select One
1J Destructive of Property/Fire Setting Select One
U Stealing Select One
_ Self-injurious Behavior Select One
Substance Abuse Select One
Presence of Psychiatric Symptoms/Conditions Select One
Enuresis/Encopresis Select One
U Runaway Select One
❑ Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
❑ 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)
❑ Emancipation Select One
Eating Problems Select One
Boundary Issues Select One
❑ Requires Night Care Select One
U 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)
.: :5" '''' . '.,..,' . ..- '.: '''''
County Basic ° Age 0-10...$16.73 1,11i 11,!!!!!1: $12.14 $0.00
$.66 e 1 No crisis intervention,Minimal
Maintenance .'t Age 11-14...$18.50 e .t Not needed or cover
Rate Srill Age 15 21...$19.75 "r CPA involvement,one face to (M under Medicaid 111,• face visit with child per month. s_t PA ta Vidrb usr $15.51 ,.
a.: $5.05
�.,#•. Minimal crisis intervention as x Regularly Scheduled
1 r r' $20.22 - $.66 needed,one face-to-face visit 1 $3.39
thRI:Aterapy up to 4 :�;y
' 4 `,�s1 per month with child,2 3 r:w hours/month.
#{ " „, 3 f contacts per month
1 % X.41 $23.59 ( k $.66 $17.19
r
i s a
� ' 79. $18.88 '•" $10.11
si, "` Occasional crisis intervention as Weekly scheduled
2 11111
$26.96 1.14:s1
$66 t r needed,two face-to-face visits e: therapy 5-8 hours a $4.89
x. month with 4 hours of -
t with child,2-3 contacts per
,€ {�! month group therapy.
xt,5. a
2'% '..� $30.33 $66 • 71
$20.56 ti
t i
I.:7.1
s 1 $22.24 1 $15.16
i, a r ' Regularly scheduled
# s. Ongoing crisis intervention as weekly,multiple kg!
a•t• ' needed,weekly face-to-face V11 sessions,can include $6.39
3 th $33.70 A $66 'r
s visits with child,and intensive more than 1 person
;? coordination of multiple i.e.family therapy for
(AM
iffii':≥ services. 9-12 hours/monthly
�r
3 1/2 t $37.06 �: $66 is as: `` $23.93
oilx 711`'1 F. $25.61 :_i
'r 4 11 �4.11
Ongoing crisis intervention as o
4 e l needed,which includes high
RCCF rill $66 level of case management and Negotiated
ill
Drop Down 1 CPA involvement with child and ,;°
,., :it1111 �)• provider and 2-3 face-to face ,.,'p
" swc, -2 contacts per week minimum
iri.11Nw�.....x ._. pica ._..'4':''''‘.''''''i P it'ww ...w t a.• ..v.kp... i., .v.:h c ....�...�.....:. ....t ..'e:'....1 ....,. :,. ..., ..,..._ .•....s
et
Assessment/ 4• . '
Emergency ' $26.96 $66 $18.88
Level Rate I17,,i iit!z;t
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT �t �,Iti n�
THIS AGREEMENT is made and entered into this day OfO(i . 20 )4.
by and between the Board of County Commissioners of Weld County, on behalfofthe Weld
County Department of Human Services, whose address is P.O. Box A. Greeley. CO. 80632.
hereinafter referred to as, "County," and Terry, Royce and Rebecca, whose address is 166499
E 42 Rd., Ringwood, OK 76768. hereinafter referred to as. "Contractor." This Agreement
covers all children placed by County with Contractor.
WilNESSI II:
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
WI IEREAS. County may. but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the 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 fix 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.
C\\'S-7A Individual lion i der Contract I Ito ised64(14
II. AGREEMENTS OF TI IE PARTIES:
A. Contractor agrees:
I. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
2. To safely provide the 24-hour physical care and supervision of each child until
removed or until the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives. and
participate in the development of the Family Service Plans for children in
placement, including visits with their parents. siblings, and relatives, or transition
to another foster care facility.
5. to maintain approved standards of care as set by the State Department of Human
Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the
Department.
10. To allow representatives of the County Department to visit the foster home and to
see the child at any reasonable time.
I I. To give the County Department two weeks notice, except in an emergency. to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department. as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
Cws-7A Individual Provider Contract 2 RCN bed 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.
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.
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 (Hll'AA).
15. To attend core certification training prior to the placement of any child.
16.To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
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
('WS-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 ofthe 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, 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.
C\A'S.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 he based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
10. '1'o provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
II. To invite the provider to Administrative Reviews for Children in placement.
12.To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14.To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement ofeach child
in writing on the required form, which shall become an addendum to this contract.
subject to all the terms and conditions hereof.
C'WS-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
alorementioned 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 lOr
audit purposes for at least five years after final payment hereunder.
C\1'S-7A Individual Provider Contract h Ito iscdl n 2(114
L
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
olColorado and be in accordance with the policies. procedures. and practices of
County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant.and further.
Contractor represents. warrants. and agrees that it has verified that Contractor does
not employ any illegal aliens. If it is discovered that Contractor is an illegal
immigrant, employs illegal aliens or subcontracts with illegal aliens. County can
terminate this Agreement and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
1. Are not presently debarred. suspended. proposed for debarment.and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not. within a three-year period of preceding this Agreement. been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining,attempting to obtain, or performing
a public (federal, state,or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement.
theft, forgery, bribery. falsification or destruction of records. making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state.or local) with commission of any of the offenses
enumerated in paragraph (B)above.
4. Have not within a three-year period preceding this Agreement. had one or more
public transactions(federal. state, and local) terminated for cause or default.
('WS-7A Individual Provider Contract 7 Revised 6/2014
N. In addition to terminating this Agreement. in accordance with the provisions of
Section I., above. County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope of
work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include. but
are not limited to. any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission.
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement. or other agreements between County and Contractor, or as a debt to
County. or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees. and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their •
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may' possess. nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge
and agree that no part of this Agreement is intended to circumvent or replace such
immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor. within five (5)calendar days after being served with a summons.
complaint, or other pleading which has been tiled in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors.
and filings in bankruptcy. reorganizations and/or foreclosure.
C'\VS-71\ Indk idual I'nn ider Contract X Robed 0/2014
WHEREFORE. the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County. on behalf of the Weld County Department VO •
J
ATTEST:
NilifeA / � L of Human Services
By: (�1W�1 UrW tik/luyCI
eputy Clerk to the Board Iarbara Kirkmeyer, Pro-Tem
CONTRACTOR: OCT 2 7 2014
Approval as to Substance:
WELD COUNTY DEPARTMENT Terry. Royce and Rebecca
OF HUMAN SERVICES 166499 F 42 Rd.
Ringwood. OK 76768
By: By: m'/201/l*
unty Di ector's or desi ee's) Contractor's (or designee's) Signature
Si nature • id Dat tLate n /, �/
By: � C-t_SK.� jk �JJ� /"t
Contractor's(or designee's�S ghatur�
and Date
CWS-7A Individual l'roc ider Contract 9 Revised612n14
o7ol - 335E
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this 2 2 day of Avc c' s r , 20 /y ,
by and between the Board of County Commissioners of Weld County, on behalf of the Weld
County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632,
hereinafter referred to as, "County," and Van Den Elzen,Dawn, whose address is 5819 W 16th
St Ln, Greeley, CO 80634, hereinafter referred to as,"Contractor." This Agreement covers all
children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as"Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014,to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty (30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
I. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
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
Ill. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
I. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local)with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local)terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
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.
It expressly understood and agreed
ed that the enforcement of the terms and conditions
O. is p y g
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5)calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: V Met) C of Human Services
Mae
By:
D puty Clerk to e
AV
L1/4? Barbara Kirkmeyer, Pro-Tem
0CT 272014
ONTRACTOR:
Approval as to Substanc'
WELD COUNTY DEPA' '�rL� ' Van Den Elzen, Dawn
OF HUMAN SERVICES 5819 W 16th St Ln
�
By: �I ul�.i �I . . .l. By: , t,//wmS 8-2z—Zoi5!
to my D' 'ctor's . desig Q 's) Contractor's(or designee ) Signature
Signature . id Date and Date
By:
Contractor's (or designee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
AC1�-330z)
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Van Den Elzen,Dawn, hereinafter referred to as, "Contractor."
GENERAL PROVISIONS
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#44282. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 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 he defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would 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.
I0. Maintain/update medication logs on a daily basis, if child is taking medications.
II. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not,within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
CWS-7A Individual Provider Contract I I Revised 6/2014
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. 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 I}
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7)questions are mutually exclusive.
P I. I 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?
P6. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing, grooming,physical,and/or occupational therapy?
Al. How often is CPA/County case management required?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling .
group
or more than one County foster child is with the same provider.
TI. How often are thera. services needed to address child's individual needs .-r NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) - Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cruelty to Animals Select One
❑ Verbal or Physical Threatening Select One
U Destructive of Property/Fire Setting Select One
Stealing Select One
Self-injurious Behavior Select One
U Substance Abuse Select One
Presence of Psychiatric Symptoms/Conditions Select One
Enuresis/Encopresis Select One
I Runaway Select One
Sexual Offenses Select One
Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
❑ Delin uent Behavior Select One
Depressive-like Behavior Select One
Medical Needs-(If condition is rated "severe",please Select One
O
complete the Medically fragile NBC)
Emancipation Select One
- — Select One
Eating Problems Select One
Boundary Issues Select One
Requires Night Care
Education Select One
U Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
I
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
It'
4e $12.14 $0 00
County Basic Qom`.-Y-Y Age 0.10...$16.73 •$.66 s No cnsis intervention,Minimal ,,,-
Maintenance w,:3 Age 11-14...$18.50 Not needed or cover
y CPA involvement,one face-to- under Medicaid
Rate L Age IS-_ ..S 19.75 . ... face visit with child per month
r s $15.51
_-- $5.05
. 47. Minimal crisis intervention as 3
Regularly Scheduled - $3.39
I $20.22 5.66 2. needed,one face-to-face vast �!
A ? _ therapy up to 4
- per month with child,2.3 hours/month t-',"-?
M contacts per month 4 yrv3.
a
1 % ,j $23.59 ---I- $.66 -,' $17.19 •fit rN
-: :'v` $10.11 :,'w::
so y $188R 6
r' °: Weekly scheduled 7'
Occasional crisis intervention as Y
2 ar; $26.96 $66 d, needed,two face-to-face visits therapy 5-8 hours a = $4.89
1.
with child,2-3 contacts per month with 4 hours of
month group therapy.
2'% $30.33 $.66 $20.56 - -- -i.t
$22.24 , $15.16 M
,^', • Regularly scheduled
` Ongoing crisis intervention as weekly,multiple
3 �"• $33 70 - $.66 needed,weekly (ace-to-face sessions,can include $6.39
'4 .. visits with child,and intensive
more than I person
p'- coordination of multiple i.e.family therapy for
_- _, services. r. 9-12 hours/monthly.
Ire
31/2 ::4-.4 $37.06 $.66 $23.93
-m.' $25.61 = ,
': Ongoing crisis intervention as ....31
4 , needed,which includes high
RCCF k $40.44 ~' $.66 level of case management and ------- Negotiated
`- 're
Drop Down ...T4 CPA involvement with child and r:.-'.
y.« provider and 2.3 face-to face ".
11
- contacts per week minimum. -. ..
n
:.m d
Assessment/
.�.,: Aaa, .:.:u
Emergency i $26.96 4. 4 $.66 $18.88
Level Rate .- 7 4
Exhibit C to the Additional Provisions 14 Revised 6/2014
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT n�,�-
THIS AGREEMENT is made and entered into this Gl / day oftak , 20 11-1,
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 Wade, Michael and Jodyne, whose address is 1016
Cottonwood Dr, Windsor, CO 80550, hereinafter referred to as, "Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1, 2014, to and until June 30, 2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 1 Revised 6/2014
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.
r for each child/youth and
21. To maintain medical, dental and educational records y
supply updated information to the County Department.
22. To conform with and abide by all rules and regulations of the Colorado
Department of Human Services, the Colorado Department of Health Care Policy
and Financing (if appropriate), the State of Colorado and any applicable federal
laws and regulations, as such, which may be amended from time to time, and shall
be binding on Contractor and control any disputes in this Agreement.
23. To maintain a current license and maintain license requirements as specified
under State law and rule.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times during the term of this Agreement a liability insurance
policy of at least $25,000 for property damage liability, $150,000 for injury
and/or damage to any one person, and $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
CWS-7A Individual Provider Contract 3 Revised 6/2014
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records, documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection, review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
I. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public(federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local) terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
1. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
CWS-7A Individual Provider Contract 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
L County, on behalf of the Weld County Department
�'j ATTEST: ia,44,J .JC,Lto:ok of Human Services
i
4
D puty Clerk to t &t /,�irarbara Kirkmeyer, Pro-Tem
OCT 2 7 2014
tu' \[ .0 �� TRACTOR:
Approval as to Substanc WELD UNTY DEPAOF HUMAAN SERVICES' r•f'r�ft ft* 016 Cottonwood Dr
ade, Michael and dyne
Windsor, CO 80550
By: - By. LkiAQ gl141
m i y Dire tor's design 's) on c s (or designee's) gn ture
i ature an Date and Dad,By:
_/�
Contractor's (or designee's) Si nature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
010/1/-3351
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Wade, Michael and Jodyne, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit 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# 1554152. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4`t' of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five(5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
CWS-7A Individual Provider Contract 10 Revised 6/2014
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
1. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7A Individual Provider Contract 11 Revised 6/2014
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7)questions are mutually exclusive.
Pl. How often does the child require transportation by the foster care provider for the following: Select One
Therapy; Medical Treatment: Family Visitation: Extraordinary Educational Needs;etc.,as outlined
in the treatment plan'?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions'?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan'?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
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 thera• services needed to address child's individual needs per NBC assessment'? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cruelty to Animals Select One
❑ Verbal or Physical Threatening Select One
❑ Destructive of Property/Fire Setting Select One
Stealing Select One
❑ Self-injurious Behavior Select One
Substance Abuse Select One
❑ Presence of Psychiatric Symptoms/Conditions Select One
❑ Enuresis/Encopresis Select One
❑ Runaway Select One
❑ Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
❑ Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
Medical Needs -(If condition is rated"severe",please Select One
❑
complete the Medically fragile NBC)
❑ Emancipation Select One
Eating Problems Select One
Boundary Issues Select One
Requires Night Care
Select One
Education
Select One
Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
mx xi 'v�P ' 'k Cr: -.'-7.' "*P- ' •
�` •�� � f � i t"�� .� � ._tit t 1 '114aoxvtlpilt mr -,,Ai),/,IINIKIne,,,..olk..4., I xtstj(e q;`._
rw' ' 1:' -h ....,:-..—;--,f-'tic's"; -ct "......J P Fx n ' c
?OW 1..x„4 ff x 1#' r - *iea x � ;• i d i , •c i
' .1'l�''A7YY # i Sl ( c . l ..t n� 9�' ate,'
-. x312" a,",=-p•, ,.w w t^.,' ,..r, r*w t.�
ki. $12.14
County Basic . Age 0-10...$16.73 $.6G '. $0.00 Un.
No crisis intervention,Minimal 4d'
Maintenance - Age II-14...$18.50 ea: Not needed or cover Yi'
,' CPA involvement,one face to ".t
Rate S. Age 15-21...$19.75 ,,q - under Medicaid.
t,hn. 3 face visit with child per month j
51
,h S5.05
Minimal crisis intervention as , Regularly Scheduled r,
1 $20.22 5.66 needed,one thee-to-face visit 53.39
therapy up to 4 L
per month with child,2-3 hours/month.
. y contacts per month
I 1/2sit-
$23.59 4 $.66 ` 517.19 5K',
f;
,,, 518.88 , 510.11
} Occasional crisis intervention as �rsi Weekly scheduled
2 $26.96 $.66 st,f needed,two face-to-face visits 1. therapy 5-8 hours a S4.89
Ear with child,2-3 contacts per 'a f month with 4 hours of
t � {' month °. group therapy.
2 14 $30.33 "'5 S.66 at` 520.56 -----------
522.24 $15.16
,le Regularly scheduled
r # , Ongoing crisis intervention as weekly,multiple
3 $33.70 5.66 needed,weekly face-to-face sessions,can include 56.39
;; visits with child,and intensive more than t person,
-,. coordination of multiple i.e. family therapy, for
services. 9-12 hours/monthly.
•
31/2 L'; $37.06 - 5.66 #sc 523.93 .
525.61
' Ongoing crisis intervention as c‘p. `
4 'I .¢* needed,which includes high '
RCCF A $40.44 f.. 5.66 level of case management and Negotiated
Y
Drop Down ' _ • CPA involvement with child and e
't `1, provider and 2 3 face-to face A it
contacts per wyeek minimum It�� x %.r, a+ t t T ::; ,?,,,3fra_SA T'w'ekv":±4;,t It . ,2:: .:'', Ki.i r.
Assessment/ v`.
Emergency $26.96 $.66 ^ $18.11$ ^
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 27 day of OCyI ta,/U , 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 Willert, Melody D and Lee, Kimberly, whose address
is 219 N 4th St, LaSalle, CO 80645, hereinafter referred to as, "Contractor." This Agreement
covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
1. TERM:
A. The term of this Agreement shall be from July 1, 2014, to and until June 30, 2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 1 Revised 6/2014
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 vile.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times during the term of this Agreement a liability insurance
policy of at least $25,000 for property damage liability, $150,000 for injury
and/or damage to any one person, and $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
CWS-7A Individual Provider Contract 3 Revised 6/2014
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records, documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection, review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
I I. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor
represents, warrants, and agrees that it has verified that Contractor does not employ
any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement
and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
I. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
CWS-7A Individual Provider Contract 6 Revised 6/2014
public transactions (federal, state, and local) terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section 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,
by deducting from subsequent payments under this
error, fraud, and/or defalcation 9 P Y
between County and Contractor, or as a debt to
Agreement, or other agreements
6
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
dal/WV County, on behalf of the Weld County Department
ATTE' ST: •,4, of Human Services
By: 1!`S 1..���� [AIL�. ' ��► /� ��i.�l k i
Deputy / ti-
Clerk to th o �t �/
, arbara Kirkmeyer, Pro—Tem
test 0 I1/41° TRACTOR: OCT 2 7 2014
Approval as to Substance,
WELD COUN'T'Y DEPA '�� 1 en, Melody D and Lee, Kimberly
OF HUMAN SERVICES y Q in. 9 N 4th St
LaSalle, CO 80645
By. BY: SY\ W 49 9 `O-\3 OA
—
r unty D'ir:. tor's ( designe s) tontracto .s or designee's) Signature
Sim mature.a • Date andVDate
•
•
By: (//1,ti� l f( tSGIJI ) 1-'44
Contractor's(ot{d ignee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
Ao) /- 3356
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement," hereinafter
referred to as, "County," and Willert, Melody D and Lee, Kimberly, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
I. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit 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# 1540372. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4111 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
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,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 her NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cntelty to Animals Select One
❑ Verbal or Physical Threatening Select One
❑ Destructive of Property/Fire Setting Select One
❑ Stealing Select One
❑ Self-injurious Behavior Select One
❑ Substance Abuse Select One
❑ Presence of Psychiatric Symptoms/Conditions Select One
❑ Enuresis/Encopresis Select One
❑ Runaway Select One
❑ Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
❑ Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
Medical Needs-(If condition is rated"severe",please Select One
❑
complete the Medically fragile NBC)
❑ Emancipation Select One
❑ Eating Problems Select One
❑ Boundary Issues Select One
❑ Requires Night Care Select One
❑ Education Select One
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 y� Y 7/01/2014)
Y yN{•,r' Y-'Y Zv .P'.'^Ji:T:'� .MS }.
f i1X ,i I3' T
q •
i y"�xag�lr� a ..,,;,,,,z4,,,.„,,,,,,,.,\ 1it'-1, .x„�`....� -- _i • . i / f}IK�1 44iisi. * I iinft:,q \is01. 1:, f t '_iilf l, .. •
• a•'k:ii;,{d,{i�'�Y"svo i $hM Cf tPb+ "",l/r�x,., kpa`t,,-Nefr. V 'IiK,3Et 'ti i s .,�i a;:Ii.x ° .di i,r .tt i I.'£ ;r J • -I
:.74/AL,,,
. I iiCi _..s„' 'i K,.
`b
s.
�.' $12.14
County Basic •f' Age 0-10...$16.73 ₹ '- 50.00
4. g $.66 No crisis intervention,Minimal 'Q. Not needed or cover .
Maintenance ' Age I1-14...$18.50 •'' ,"' _
/ CPA involvement,one face-to- under Medicaid. `
Rate • Age 15-21...$19.75 ' ' -`.k: face visit with child per month.
t.-1:1i
�' S15.51 .� �,1
''"I;'•,;.„:::.:
.yF $5.05 q
Minimal crisis intervention as Regularly Scheduled • '
1 5, $20.22 r $.66 needed,one face-to-face visit is therapy up to 4 '. ] 33.39
5 per month with child,2-37. hours/month.
≥2:: contacts per month _
1 '% $23.59 $.66 $17.19 it •
c. '
S18.88 $10.11
4 `
•
Occasional crisis intervention as Weekly scheduled "s
' needed,two face-to-face visits therapy 5-8 hours a 2 $4.89
2 - $26.96 $.66
'` month with 4 hours of
rye with child, 3 contacts per . a
{ .iti x' month group therapy. ...
'?°
2 '/z $30.33 $.66 $20.56 ,+
:S
^v^ $22.24 `- $15.16
_ . Regularly scheduled
Ongoing crisis intervention as . : weekly,multiple
i
3 ' 'r needed,weekly face-to-face sessions,can include • $6.39
$33.70 4 $.66
visits with child,and intensive more than 1 person,
x coordination of multiple
{,ry - . . i.e, family therapy,for .
At. *f' services. 9-12 hours/monthly. `
F_^ Iii
31/2 1; $37.06 4 $.66 0 $23.93
• r;f
A $ i61
Ongoing crisis s intervention as h„ '
4 needed,which includes high ;f
RCCF + $40.44 1 $.66 • level of case management and Negotiated
Drop Down CPA involvement with child and
provider and 2-3 face-to face
��,{�$. ,,��y,Fp}� .k contacts per week minimum. ` .
�.. F"'°9't .`.Y �`�� - • �'-,rte ..S Y. • •
A
Assessment/
Emergency • $26.96" $.66 $18.88 §
41 i
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 2\day of ACV US-k- , 20
by and between the Board of County Commissioners of Weld County, on bet:calf of the Weld
County Department of Human Services,whose address is P.O. Box A,Greeley, CO, 80632,
hereinafter referred to as, "County," and Wurtz,Drew and Workman-Wurtz, Katherine,
whose address is 1901 15th Street, Greeley, CO 80634, hereinafter referred to as, "Contractor."
This Agreement covers all children placed by County with Contractor.
WITNESSETH:
WHEREAS,the Colorado State Department of Human Services (hereinafter referred to
as"State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the Facility's certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from July 1,2014, to and until June 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30)days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first,and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
i parties shall not be released from the duty to perform their obligations up to the date
I d of termination.
11. AGREEMENTS OF THE PARTIES: ,v
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 1 Revised 6/2014
i
I
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. 1
b. Any major illness of the child.
1
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
C� G1 I County, on behalf of the Weld County Department
C�-
ATTEST: G t.C. of Human Services
By: ♦ I. / I . . �°Q'/��1'a Z ,f G ,, //1 J t A.—
Deputy Clerk to the 'Lard1"' , bara Kirkme 'er, Pro- -m
1861 r�k?.U' '� RACTOR: OCT 2 7 Z014
Approval as to Substance:
WELD COUNTY DEPART�t%ij 1x sit~%r,Drew and Workman-Wurtz, Katherine
OF HUMAN SERVICES ��- .- 9*1 15th Street
Greeley, CO 80634 By: By: g02-1iI 1 id
o my Dire tor's (o esign s) ontractor's (or design Signature
ig ature n Date and Date
By:
.0/g0/7
C or's (or designee's) ignat re
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
N- 33�A
EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care Services and Foster Care Facility Agreement
CWS-7A
The following additional provisions apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement,"hereinafter
referred to as, "County," and Wurtz,Drew and Workman-Wurtz,Katherine, hereinafter
referred to as, "Contractor."
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit as Exhibit 8, 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# 1633330. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided,the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25)calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 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. l
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain,access and review information weekly on F1DOS.
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 F1DOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. 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
1
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
' EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven (7)questions are mutually exclusive.
Pt. How often does the child require transportation by the foster care provider for the following: Select One
Therapy; Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc.,as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy?
i
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 i
group
or more than one County foster child is with the same provider.
11.How often are thera. services needed to address ild'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
NJ 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
li Enuresis/Encopresis Select One
ERunaway Select One
Sexual Offenses Select One
Inappropriate Sexual Behavior Select One
Disruptive Behavior Select One
Delinquent Behavior Select One
Depressive-like Behavior Select One
o Medical Needs-(If condition is rated"severe",please Select One
complete the Medically fragile NBC)
❑ Emancipation Select One
Eating Problems Select One I
—
Boundary Issues Select One
Requires Night Care Select One
r Education Select One
❑ Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
i
I
4 • A
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
�fcl�i i r { '` k''' tl 1 s.�ti ry 1 ]l•r � .x`-::%•---2.-..1--• 1 f! 35•,1fAi tt' t Jiff �r�' t i t 1 Ir•- V
}lY'h aK` t au k "1�7� �.1;'�'`, ��'' ` .:f `1Ui�,yj,7: • ``Ifs,':/-i_��j Yl'�',rdrgf E'-h' ;‘..:::44,16?!..-L
r .'....,t_",'_�' is ' : 1r r}� iii -,10,k"--:-.;-.-:,• ".,` ,,, . -..,.-,.):_w,%1*
L,.-Ye,vetr� ` ii air a ', f e- ., .; 4n #6 o Or {` ,a t'1 ar,:: r aD Ti,k,
$12.14 i
County Basic Age 0-10...$16.73 5.66 No crisis intervention,Minimal $0.00 •Maintenance Age 11-14...$18.50 f: • Not needed or cover _ - —
rr Agc 15-2 L..$19.75 .`° CPA involvement,one face-to- ) under Medicaid.Rate face visit with child per month. - I
-.,.,
ti $15.51 $5.05
...1`s
"h, Minimal crisis intervention as
1 $20.22 5.66 r: `' Regularly Scheduled $3.39
needed,one face-to-face visit therapy up •„, $
to 4
"e• per month with child,2-3 hours/month. .
ved contacts per month ,#,I
Y.
1 h $23.59 5.66 4 $17.19 ,` _— _...__...
- i
$18.88 510.11 •
Occasional crisis intervention as Weekly scheduled
2 i
$26.96 x 5.66 ' needed,two face-to-face visits f therapy 5-8 hours a $4.89
with child,2-3 contacts per • ;, month with 4 hours of =
month _,-_; group therapy.
2'/: $30.33 r $.66 $20.56 •�� ---- ---
r $15.16
$22.24
Fx ? Regularly scheduled -
Ongoing crisis intervention as ',.`1 weekly,multiple _
3 $33.70 3` $•66 needed,weekly face-to-face + sessions,can include ' $6.39
visits with child,and intensive
more than 1 person,
coordination of multiple 3
'r ,, , i.e.family therapy,for :k'
services. 9-12 hours/monthly.
3lR u 537.06 ; 5.66 A,i $23.93 ---
N $25.61
ki, •0• Ongoing crisis intervention as
4 t-- . needed,which includes high
RCCF $40.44 $.66 k }}' ::'..4 Negotiated
level of ease management and - g
Drop Down CPA involvement with child and
N' provider and 2-3 face-to face ...''''-• -
• contacts per week minimum.
Assessment/
Emergency 526.96 :,r 5.66 $18.88 ------
Level Rate
I
Exhibit C to the Additional Provisions 14 Revised 6/2014
I
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
q ' o!
THIS AGREEMENT is made and entered into this 21 day of (J(/I(�,,C,� , 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 Yingling, David and Nicole, whose address is 50151
County Road 15, Wellington, CO 80549, hereinafter referred to as, "Contractor." This
Agreement covers all children placed by County with Contractor.
W ITN ESSITH:
WHEREAS, the Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
I tome/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 I, 2014,to and until .tune 30,2015,
or until the Facility's certificate/license is revoked or suspended.
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty (30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty (30) days, or until the eligible children) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of teen'nation.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
I. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
C'WS-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 in the development of the Family Service Plans for children in
placement, including visits with their parents, siblings, and relatives, or transition
to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human
Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the
Department.
10. To allow representatives of the County Department to visit the foster home and to
see the child at any reasonable time.
II. To give the County Department two weeks notice, except in an emergency, to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of-address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or
other persons in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or
supervising agency.
CWS-7A Individual Provider Contract 2 Revised 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. "1'o pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
I I. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
Ill. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent. employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement. Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services shall be and hereby is
permitted to monitor service program, fiscal and other records sufficiently to assure
CWS-7A Individual Provider Contract 5 Revised 6/2014
the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department may provide consultation to Contractor to
assure satisfactory performance in the provision of purchased services under this
Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. Such records shall be complete and available for
audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
II. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood,earthquakes or Governmental actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perfOrm services of the same or similar nature.
L. 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
('WS-7A Individual Provider Contract 6 Revised 6;2014
public transactions(federal, state, and local)terminated for cause or default.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
Substantial failure to satisfy the scope of work shall be defined to mean incorrect or
improper activities or inaction by the Contractor. These remedial actions include,
but are not limited to, any one or more of the following:
I. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. It is expressly understood and agreed that the enforcement of the terms and conditions
of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties or their assignees, and nothing contained
in this Agreement shall give or allow' any claim or right of action whatsoever by any
other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties or their
assignees receiving services or benefits under this Agreement shall be an incidental
beneficiary only.
P. No portion of this Agreement shall be deemed to constitute a waiver of any immunity
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no par 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.
('WS-7A Individual l'rovider 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
;re County, on behalf of the Weld County Department
ATTEST. of Human Services
i A* Etta
By: �� �..Y. i'' ` _ s 'tt . ' .° AL. ' //tit
4eputy Clerk to the oa % � �sarbara Kirkm- er, Pro-"em
RACTOR: OCT 2 7 2014
Approval as to Substance: %' C
WELD COUNTY DEPAR '��r, p �. gling, David and Nicole
OF HUMAN SERVICES 0151 County Road 15
Wellington, CO 80549 L tni By: By: �� n tt n LLsF'
my Di r ctor's ( design 's) Con actor's (or des ne s) Si nature
i atu a d Date and ate
By: tJ S4Sry
Contractor's( lesignee's) S Lure
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
X0/1/-33
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 Yingling, David and Nicole, 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# 1639142. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but arc not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4i° of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25)calendar days of
the month following service, it may result in forfeiture of payment.
C'WS-7A Individual Provider Contract 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.
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 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 Stall Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C'. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five (5) calendar days after being served with a summons,
complaint,or other pleading which has been filed in any federal or state court or
CWS-7A Individual Provider Contract 10 Revised 6/2014
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy. reorganizations and/or foreclosure.
CONTRACTOR SHALL:
I. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall 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. I lave physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain,access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis. if child is taking medications.
I I. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7.4 Individual Provider Contract I I Revised 62014
•
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.
I 3. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
EXIIIBIT 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. 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. I low often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
PS. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing.grooming,physical,and'or occupational therapy?
Al. How often is CPA/County case management required?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
Ti. How often are thera. services needed to address hilt's individual needs rer NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
u Aggression/Cruelty to Animals Select One
IVerbal or Physical Threatening Select One
Destructive of Property/Fire Setting Select One
Stealing Select One
Self-injurious Behavior Select One
�_ Substance Abuse Select One
u Presence of Psychiatric Symptoms/Conditions Select One
Enuresis/Encopresis Select One
Runaway Select One
U 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
ell
Requires Night Care Select One
—pa—
_ 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)
II
tit P j .-
v rlS/
A
(bunt) Basic Age(1-10 .$16.73 ... 1 31n 14 ) 50.0!1 .11
5.66 Ni,onus linenentiun-Minimal ,
Slaintenance =,-;-.., Age I I-14..318.50 � �. Not nccdcd or cover
+sa CPA involvement.one face-to 8 }h�
Rate Age 15-21...S19.75 y..4 -3 e < under Medicaid. Y �1
r' lace visit with child per month
ri
.__. -:8 Vii_._—_ .T 515.51
$5.05
h' t_ , Minimal crisis intervention as `
• Regularly Scheduled .+%
1 S2f1.22 $.66 wry needed one Iaee-to-face visit IA 53.39
Vt." re therapy up too xt%
yr per month with child,2.3 ,r' °
hourshnonth.
te r' contacts per month
$23.59 $.66 1 $17.19 4i
'r'' -T T fa $18.88 kit $10.11 th
%,,,,..j..,. Occasional crisis intenenuon as I Weekly scheduled
2 lie $26.96 5.66 7, needed two lace-to-lace visits 'r therapy 5-8 hours a :%'-,1 $4.89
x.
✓',,. with child.2-3 contacts per '� month with 4 hours of 2*'.
vbg f' nthi month a�1d group therapy.
t 7 p ,
2 A $30.33 '' -a
5.66 5211.56 ." 4
t
,Y.�'aT tip $ 4 2) 2 r v SI5.16
rill v: ii'i Regularly scheduled
4 ,.. Ongoing crisis tntcn cntion as weekly-multiple
3 $33.70 5.66 S� needed.weekly face-to-face sessions,can include rs�.%q; $6.39
visits with child,and intensive tj more than I person r5
t " Coordmalioo of multiple . '
1 ; ix.tamely therapy,for
scn ices. 9-12 hoursln onthly.
c
31/2 . liatii
:; $37.06 5.66 $23.93 it
,;;x h3
74 525.61 µ
rid 1 A Ongoing er1 o.ink:mention as `+i
4 d needed,which includes high a '
R('CI 5411.44 5.66 " level of case management and athcsoark Negotiated
Drop Down r9 CPA involvement snub child and #te s
AM Ssi.1r , provider and 2-3 face-to face ry 4
^) contact:per week minimum. .
sass i:i
•
P:-.1 *ft:I,'" e, k-4' '°PI .4 i it.t ! ?';si .. *,a xa;S'ruf7d::.1.111"9')'!"44.q.1
\ssessment/ t'
Emergency - S26.96 5.66 SIt " $18.88 ,e
•,s
Level Rate sr': ?
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 thi day of IOC/Mt , 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 Simmons,Michael and 13ava,whose address is 1117
Alpine Ct.,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. k(I
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. j
B. Each party shall have the right to terminate this Agreement by giving the other party
written notice received at least thirty(30) days prior to the intended date of
termination. If notice is so given, this Agreement shall terminate upon the expiration
of thirty(30) days, or until the eligible child(ren) may be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease; however, the
parties shall not be released from the duty to perform their obligations up to the date
of termination.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
CWS-7A Individual Provider Contract 1 Revised 6/2014
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 F
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. 1
23. To maintain a current license and maintain license requirements as specified
under State law and rule.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times during the term of this Agreement a liability insurance
policy of at least$25,000 for property damage liability, $150,000 for injury
and/or damage to any one person,and $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
CWS-7A Individual Provider Contract 3 Revised 6/2014
27. To indemnify County and the State Department against any and loss against all
claims and actions based upon or arising out of damage or injury, including death,
to persons or property caused or sustained in connection with the performance of
this Agreement or by conditions created thereby, or based upon any violations of
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To maintain service program records, fiscal records, documentation and other
records, which will sufficiently and properly reflect all direct and indirect costs of
any nature incurred in the performance of this Agreement. The above shall be
subject at all reasonable times to inspection,review or audit by federal, State
Department, or County personnel, and other persons authorized in writing by the
State Department Executive Director.
B. County agrees:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs,and separation/loss
issues.
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
CWS-7A Individual Provider Contract 4 Revised 6/2014
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes.The county
department is responsible for providing information on county specific
procedures.
1 I. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied,to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services 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.
L. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws of
Colorado and be in accordance with the policies, procedures, and practices of County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. 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:
l. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
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 7 Revised 6/2014
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: Co CI ,,. / .64. of Human Services
By: r.�/ �f( �. ,By tLU. ltiL�/ �'C . �✓
deputy Clerk to th «. ' Barbara Kirkme}/er, Pro- em
testa"-
" OCT 2 7 2014
Il 61 NTRACTOR:
Approval as to Substance
WELD COUNTY DEPAR mmons, Michael and Hava
OF HUMAN SERVICES \‘' 1117 Alpine Ct.
Winds r, CO 80550
By: � " By: $ y11-1 I
ty Dire.tor's (or d signee' Contractor's or designee's) Signature
ig ature a • Date and Date
By:
Contractor's (or designee's) Signature
and Date
CWS-7A Individual Provider Contract 8 Revised 6/2014
3356
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 Simmons, Michael and Hava, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
l. 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 (I
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# 1645970. These services will be for children who have been
deemed eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 7 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Contractor.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25) calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 9 Revised 6/2014
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Contractor, within five (5)calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
CWS-7A Individual Provider Contract 10 Revised 6/2014
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
1. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on FIDOS.
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
CWS-7A Individual Provider Contract 11 Revised 6/2014
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local)with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
CWS-7A Individual Provider Contract 12 Revised 6/2014
•
EXHIBIT B
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine the NBC Care Payment. For each question below please select the
closest rating for this child. The following seven(7)questions are mutually exclusive.
P1. How often does the child require transportation by the foster care provider for the following: Select One
Therapy;Medical Treatment;Family Visitation;Extraordinary Educational Needs;etc.,as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P S.How much time is the provider required to assist the child because of impairments beyond age Select One
gpprooriate needs with feeding,bathing,grooming,physical,and/or occupational therapy?
Al. How often is CPA/County case management required?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
T1.How often are therapy services needed to address hild's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
' Assessment Areas: Comment: Rating:
[� Aggression/Cruelty to Animals Select One
❑ Verbal or Physical Threatening Select One
-
❑ Destructive of Property/Fire Setting Select One
❑ Stealing Select One
❑ Self-injurious Behavior Select One
❑ Substance Abuse Select One
❑ Presence of Psychiatric Symptoms/Conditions Select One
❑ Enuresis/Encopresis Select One
❑ Runaway Select One
_❑ Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
❑ Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
❑ Medical Needs-(If condition is rated"severe",please Select One
complete the Medically fragile NBC)
_:1— Emancipation Select One
Eating Problems Select One
Boundary Issues Select One
Requires Night Care Select One
❑ Education Select One
❑ Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
• EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
t2c:3m sly X4 ;,'.9.',.11,1.0).' j $ ,. u4tp 6n7vNnna .,ti.,, ,3 . is u+7�(
ti; fl I" ,.di tin uf'Iv`( ,; • ; ::';‘7,-.414N5.;,.;,_,.,,;(..;;;;',' ! 9�„ t. .; � f� ' a r
4''''''‘a-11
— " e
r " e Ieitir ;ism.; it u ,15i�:;t 1 Z imy Y_ i Lei 1,;:l 4i,,.: f n is i
. ..
County Basic x Age 0-10...S16.73 -i > $12.14 ..r $0.00it
- $.66 No crisis intervention,Minimal - '
Maintenance Age 11-14...$18.50 . t Not needed or cover
''tiCPA involvement,one face-to t
Rate Aye IS-21...$19.75 . " - under Medicaid. `
Y ' s`k face visit with child per month. ry;
'v.+ fz $15.51 $5.05
•a" '? Minimal crisis intervention as f-
-Y ;`3 Regularly Scheduled
1 :s $20.22 ; 5.66 �'y needed,one face-to-face visit $3.39
fik therapy up to 4
,, per month with child,2-3 s+k hours/month.
�, contacts per month + ;
1 '% $23.59 5,66 ' $17.19 ----------
$18.88 $10.11
'1 r �' F Occasional crisis intervention as -_ Weekly scheduled
2 �^ 526.96 $.66 needed,two face-to-face visits therapy 5-8 hours a $4.89
,' with child,2-3 contacts per month with 4 hours of i
-i xi month group therapy. 4.
a7 •.
2 Y, i3 $30.33 $.66 $20.56 rl ---
�' $22.24 'I $15.16
3Y' � �" Regularly scheduled
Ongoing crisis intervention as
weekly,multiple
3 3 533.70 , $.66 needed,weekly face-to-face sessions,can include 56.39
§ , visits with child,and intensive
,,. more than I person
coordination of multiple i i.e.family therapy,for
1,.. services. :at. 9-12 hours/monthly.
1'1,-
31/2 $37.06 5.66 $23.93 ----
ry t.,2..
$25.61 t` r:
Wit; Ongoing crisis intervention as s•, i*C
4 '" needed,which includes high
RCCF $40.44 e F 5.66 .i Negotiated
level Of Case management and
Drop Down CPA involvement with child and e 'stit
45,-
gilt' provider and 2-3 face-to faceatigi
3", " ^ contacts per week minimum. =!
ic, .,try-" _..,-,ir-'*- --;,r— ::._ • t _
Assessment/ ylr
Emergency $26.96 $.66 4' $18.88 ---------
Level Rate _1i sa
Exhibit C to the Additional Provisions 14 Revised 6/2014
Hello