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Home My WebLink About20141774.tiff MEMORANDUM 1861 • ' t DATE: June 5, 2014 TO: Douglas Rademacher, Chair, Board of County Co mi ioners r 0 0 O N T T FROM: Judy A. Griego, Director, Human Servi s ep 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 are Individual Provider Contracts 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 April 30, 2014, and approved for placement on the Board's Agenda. The major provisions for these Agreements are as follows: No. Provider/Term Facility Type/Location Daily Rate 1 Brown, Rachel Foster Home $16.32 - $40.11 March 23, 2014—June 30, 2014 Greeley, Colorado 2 Buck, Jamie and Lynn Foster Home $16.32 - $40.11 March 17, 2014 —June 30, 2014 Evans, Colorado 3 Crews, Paul and Kim Foster Home $16.32 - $40.11 March 27, 2014—June 30, 2014 Mead, Colorado 4 Eckhardt, Mitchell & Shawna Foster Home $16.32 - $40.11 January 29, 2014 —June 30, 2014 Greeley, Colorado 5 Egbert, Katie Foster Home ICPC/WA State February 22, 2014—June 30, 2014 Auburn, Washington Foster Care Rtes 6 Hartness, Richard and Marlaena Foster Home $16.32 - $40.11 February 16, 2014 —June 30, 2014 Platteville, Colorado 7 Irwin, Jeremiah and Kasi Foster Home $16.32 - $40.11 March 14, 2014—June 30, 2014 Loveland, Colorado 8 White, Drew and Johansen, Amber Foster Home None/Courtesy June 24, 2013 —June 30, 2014 Greeley, Colorado FC License 9 Johnson, Heidi and Kevin Foster Home None/Courtesy April 3, 2014 —June 30, 2014 Eaton, Colorado FC License 10 Smith, Michael and Hava Foster Home $16.32 - $40.11 January 31, 2014—June 30, 2014 Windsor, Colorado 11 Smith, Stephanie and Pults, Mark Foster Home $16.32 - $40.11 January 29, 2014—June 30, 2014 Lakewood, Colorado If you have questions, please give me a call at extension 6510. 2014-1774 Cwt � .da cc: �s� r� 9 HRoo25 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this // —day of \TIM e. , 20/if, 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 Rachel Brown,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 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 7/104 ,R3 , to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease; however,the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 oW/9—/779 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 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 Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. 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 rformed 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 S-7A Individual Provider Contract 8 Revised 6/2013 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 r/ _ �C ;� County, on behalf of the Weld County Department ATTEST: of Human Services Ana BY'�Ii///.e i�`L� / C dv �1 • . \►�iYy► t• % _ Sb ou �s Rademacher, Chairman Deput Jerk to the Bo.��t. ;,t &�„ g JUN , .,;•�_ ,�� 1 1 2014 RACTOR: Approval as to Substance: -kb LI V WELD COUNTY DEPARTMENT Rachel Brown OF HUMAN SERVICES 2809 W. E. Street Greeley, CO 80631 By: /, ��_ � ' �j, '.1 CD � ,I ��By: ...Weald Fuck P3' C'Inty Iir-ctor's l.rde ignee s) Director's (or designee's) Signature S.g ature and Dat•l and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 v?0ly—/771/ EXHIBIT "A" 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 Rachel Brown, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in 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 on the Needs Based Care Rate Table, designated 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 each level of service, as indicated by the Needs Based Care Rate Table, designated 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 3 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. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit"A"to the CWS-7A 1 Revised 6/2013 • 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 r 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' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit"A"to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. 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. 11. 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. 12. 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. 13. 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. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. 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. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. 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. 18. 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. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared federal department ineligible o r voluntarily excluded from covered transactions by a p g 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; C. 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; Exhibit"A"to the CWS-7A 3 Revised 6/2013 D. 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. E. 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. 22. 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. Exhibit"A"to the CWS-7A 4 Revised 6/2013 • EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.)Less than one round trip a week DI)One round trip a week 01%)2 round trips a week ❑2)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week ❑3'/:)7 round trips or more Comments: P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? 0 Basic Maint.)No participation required ❑l)Once a month ❑1%:)Two times month ❑2)Three times a month ❑2%)Once a week 03)Two times a week ❑3%:)Three times a week or more Comments: P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements DI)Less than a ''/2 hour per day 011/4) 1/4 hour a day ❑2) I hour a day 02 %) 1'/3-2 hours per day 03)2'h-3 hours per day ❑3'/)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.)No special involvement needed DI) Less than 5 hours per week ❑1'h)5 to 7 hours per week 02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond see appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/:)5 to 7 hours per week 02) 8 to 10 hours per week ❑2%:) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/:)21 or more hours per week Comments: A I. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **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 Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month Exhibit"B"to the Additional Provisions 5 Revised 6/2013 . • EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. . ci 3 ti a _. : Far.;r 'Y 'fit, 1 i; 1( . :., -3-4./. tg.";: ','4: < tlilgp ,COnttttton . r& ..,:././..;,,;: ;'t s" '" ,� �(Che�e h"5�'tor each categor��" fi rl q..,.`, t CC at t A ... -t. r cr=}' & 4 V4-75: Assessment Areas Mites/ M°a4raw *�t� c z 3 *t. ' - r3P4 Mull Moderate. Moderato r `stlls6 J t zi t� tai r 0 1 11/2 2 '''2111, ,.^ k3 , u i . -,, i Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ 0 Verbal or Physical Threatening ❑ ❑ 0 0 ❑ 0 ❑ Destructive of Property/Fire Setting ❑ 0 ❑ ❑ ❑ ❑ ❑ Stealing ❑ 0 0 0 0 ❑ 0 Self-injurious Behavior ❑ ❑ ❑ ❑ 0 0 ❑ Substance Abuse ❑ 0 ❑ 0 ❑ ❑ 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 0 ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ 0 ❑ 0 0 0 Runaway ❑ ❑ ❑ ❑ 0 0 ❑ Sexual Offenses ❑ 0 ❑ ❑ 0 ❑ 0 Exhibit"B"to the Additional Provisions 6 Revised 6/2013 • , • EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child }` ,, I+;a nSof Conditions d = . , �° (Check one box for each categ } ., 3 = r .a4. ;,g, o- �k 'c, B 'I .. Q 4ssessmentAreas 1M Moderato v ,. e ,._ t ) me - Moderate �.+ a ` u'sk` °)i L`Rrk ✓: o o t 1 1'1/2 2 : 2 4,33'7'.# , ,<? •{ r , ' Inappropriate Sexual ❑ ❑ 0 ❑ ❑ ❑ ❑ Behavior Disruptive Behavior ❑ ❑ 0 0 ❑ ❑ ❑ Delinquent Behavior O 0 ❑ ❑ 0 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated ❑ ❑ ❑ ❑ ❑ 0 ❑ "severe",please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ 0 Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ 0 Education ❑ ❑ ❑ ❑ ❑ 0 0 Involvement with Child's Family 0 0 ❑ ❑ 0 ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'/2 ❑ 3 ❑ 3'h Exhibit"B"to the Additional Provisions 7 Revised 6/2013 EXHIBIT"C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ¢ � R %EVE s R3/1:6E r ' VE `vt. hl r lft Di r a 7. Age 0-10...$16.32/day County Basic :; Age 11-14...$18.05/day Maintenance .tt Rate Age 15-21...$19.27/day +Respite Care$.66/day $19.73 4 +$.66 Respite Care ($20.39 day) $23.01 1 1/2 +$.66 Respite Care ($23.67 day) x $26.30 2 ;,* +$.66 Respite Care ($26.96 day) $29.59 2 1/2 ,: +$.66 Respite Care ($30.25 day) 4.4 $32.88 3 +$.66 Respite Care ($33.54day) $36.16 3 1/2 +$.66 Respite Care ($36.82 day) 4 $39.45 +$.66 Respite Care RCCF Drop Down ($40.11 day) t!` ear I J $29.59 +$.66 Assessment/Emergency � Respite Care Rate ? ($30.25 day) Effective 7/01/2008 Exhibit"C"to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT U- THIS AGREEMENT is made and entered into this /I day of Jun , 20/9 , 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 Jamie and Lynn Buck, whose address is 6455 Chardonnay Street #3, Evans, Co 80620, 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 Ina Ail 17� 20/y , to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 &ON /779 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 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 Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure purchase of services in this Agreement are carried out for the benefit of the theg ro re aforementioned client. Monitoring may occur through reviewof 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 6/2013 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 from covered transactions by a federal ineligible or voluntarily excluded g 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 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. 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 8 Revised 6/2013 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 r�J County, on behalf of the Weld County Department ATTEST s°C — of Human Services 1 = r �� Douglas Rademacher, Chairman • .�� .a JUN 1 1 2014 Depu Clerk to the B TRACTOR: Approval as to Substance: 1 �' WELD COUNTY DEPARTMEN Jamie & Lynn Buck OF HUMAN SERVICES 6455 Chardonnay Street #3 Evans, CO 80620 By: t By: '3//7/ 1 C my Dir ctor' r desi ne s tin.r-dr) ctor's (or designee's) Signature S ature a d Date and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 a©��/- /77'/ EXHIBIT "A" 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 as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in 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 on the Needs Based Care Rate Table, designated 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 each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID# 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 3 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. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit"A"to the CWS-7A I Revised 6/2013 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' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit"A"to the CWS-7A 2 Revised 6/2013 • CONTRACTOR SHALL: 10. 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. 11. 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. 12. 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. 13. 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. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. 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. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. 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. 18. 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. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. 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; C. 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; Exhibit"A"to the CWS-7A 3 Revised 6/2013 D. 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. E. 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. 22. 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. Exhibit"A"to the CWS-7A 4 Revised 6/2013 • EXHIBIT"B" • • WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P I. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑1)One round trip a week ❑1%)2 round trips a week ❑2) 3-4 round trips a week. ❑2'/:) 5 round trips a week 03)6 round trips a week ❑3'/i) 7 round trips or more Comments: P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month 01%)Two times month ❑2)Three times a month ❑2'/:)Once a week ❑3)Two times a week ❑3'/:)Three times a week or more Comments: P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1) Less than a %hour per day ❑1'/:) '/,hour a day ❑2) 1 hour a day ❑2 '/:) 11/4-2 hours per day 03)2%z-3 hours per day ❑3%) More that 3 hours per day Comments: _ P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week ❑1'/z) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'/n) 11 to 14 hours per week ❑ 3)Constant basis during awake hours ❑3'/:)Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑7) 3 to 4 hours per week ❑1'/%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'/:) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%)21 or more hours per week Comments: A I. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/2) Face-to-face contact one time per month with child and occasional crisis intervention. ❑2) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/:) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **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 Contractor. T I. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month ❑2)4-8 hours per month ❑3) 9-12 hours per month Exhibit"B"to the Additional Provisions 5 Revised 6/2013 EXHIBIT"B" • WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. v Rating of Conditions (Check one box for each category) ` '' .r Assessment Areas m Modera _� f None Mild Moderate. Moderate Huh Mak Sere �'`Commit: 0 1 11/2 2 21/2 3 31/2 , Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑ Stealing ❑ ❑ El ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ O ❑ O O ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ O El ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ O Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses O ❑ ❑ ❑ ❑ ❑ O Exhibit"B"to the Additional Provisions 6 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions rts^ :o r ; (Check one box for each category) r r Rz ry Assessment Areas Mild/ Moderate/ h.p/ . None Mild Moderate. Moderate High High kith' tomnl t3: 0 1 11/2 2 21/2 3 31/2 1 41 Inappropriate Sexual ❑ ❑ ❑ ❑ El El Behavior Disruptive Behavior ❑ ❑ ❑ ❑ ❑ 0 ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ 0 Medical Needs (If condition is rated ❑ ❑ ❑ ❑ ❑ ❑ ❑ "severe",please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ 0 ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'/z Exhibit"B"to the Additional Provisions 7 Revised 6/2013 EXHIBIT"C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE RECOMMENDED LEVEL OF SERVICE CONTRACTOR RATE P1 -P5 Level Child Maintenance/Respite Age 0-10...$16.32/day County Basic Age 11-14...$18.05/day Maintenance Rate Age 15-21...$19.27/day + Respite Care$.66/day $19.73 1 +$.66 Respite Care ($20.39 day) $23.01 1 1/2 +166 Respite Care ($23.67 day) $26.30 2 +$.66 Respite Care ($26.96 day) $29.59 2 1/2 +$.66 Respite Care ($30.25 day) $32.88 3 +$.66 Respite Care ($33.54day) $36.16 3 1/2 +166 Respite Care ($36.82 day) $39.45 4 +$.66 Respite Care RCCF Drop Down ($40.11 day) $29.59 +$.66 Respite Care Assessment/Emergency $ ( 30.25 day) Rate ($ Effective 7/01/2008 Exhibit"C" to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this /1 day of Yu , 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 Paul & Kim Crews, whose address is 407 7`n Street, Mead, CO 80542, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from Thatch ,7 go/9 , to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 aoi'I—/77'/ II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human pP p 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 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 Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public(federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. 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 8 Revised 6/2013 WHEREFORE,the patties have herein set their hands and affixed their seals the day and date first written above. COUNTY: The Board of County Commissioners of Weld die/WV County,on behalf of the Weld County Department ATTEST: L u juman Services By: �u� : /.' #:.. : ��\�cw CeS R �. weJ1 Deputy &'erkto the B. .:.: lt ,�0� •i,.uglas 'ademacher,Chairman ,� JUN 1 1 2014 '•1 CTOR Approval as to Substance: %O ki WELD COUNTY DEPARTME 1 _rt "' '41 Se Kimberly Crews OF HUMAN SERVICES 407 7th Street Mead,CO 80542 1 * ! � 3 7-/ By: �1 .� .. I IL I�I� '/ pity:b ebu� +art �.�vr f� Al C. tyDire. or's o1 •es : e's Direc is(or designee's)Signature S g tureen Date and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 doiy—/771f EXHIBIT "A" 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 Paul & Kimberly Crews , hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in 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 on the Needs Based Care Rate Table, designated 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 each level of service, as indicated by the Needs Based Care Rate Table, designated 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 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4`" of each month following the month of service. If the reimbursement request is not submitted within twenty-five(25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit"A"to the CWS-7A 1 Revised 6/2013 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' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit"A"to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. 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. 11. 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. 12. 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. 13. 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. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. 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. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. 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. 18. 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. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. 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; C. 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; Exhibit"A"to the CWS-7A 3 Revised 6/2013 D. 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. E. 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. 22. 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. Exhibit"A"to the CWS-7A 4 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.)Less than one round trip a week O1)One round trip a week ❑1'h)2 round trips a week 02) 3-4 round trips a week. ❑2%z)5 round trips a week 03)6 round trips a week 031/2) 7 round trips or more Comments: P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? O Basic Maint.)No participation required ❑1)Once a month ❑1%)Two times month 02)Three times a month ❑2%)Once a week 03)Two times a week ❑3'/z)Three times a week or more Comments: P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? 0 Basic Maint.)No educational requirements ❑1) Less than a ''/z hour per day 011/2) 1/2 hour a day 02) I hour a day 02 'A) 1'/z-2 hours per day 03)2'/:-3 hours per day ❑3'%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1'/z)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%z) 11 to 14 hours per week 0 3)Constant basis during awake hours ❑3%z)Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding,bathing, grooming,physical, and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/z)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%z)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/z)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. ❑3'%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **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 Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00)Not needed or provided by another source(i.e. Medicaid) ❑l) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month Exhibit"B"to the Additional Provisions 5 Revised 6/2013 EXHIBIT"B" ' WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions £ix • ,, (Check one`box for each category#] Assessment Areas Mild/ Moderate/ nizW None mig Moderate. Moderate tick Ltd Severe Comments: 0 1 11/2 2 21/2 3 31/2 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ 0 ❑ 0 Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ 0 ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ Exhibit"B"to the Additional Provisions 6 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a ly to this child. 'Rating of Conditions i'ieirle.' .x ,x< `G4 eck one box foe each category) . „ r e , HieW ^`. ,. ,r, Assessment Areas a '4 None Id Moderate. Moderate Hrvlt"' huh ever a Comments Inappropriate Sexual ❑ El ❑ ❑ ❑ ❑ Behavior Disruptive Behavior ❑ 0 ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ 0 Medical Needs (If condition is rated ❑ ❑ ❑ ❑ ❑ ❑ ❑ "severe",please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ 0 ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ 0 ❑ ---1 4 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 E11/2 ❑ 2 ❑ 2%z ❑ 3 ❑ 3'/ Exhibit"B"to the Additional Provisions 7 Revised 6/2013 EXHIBIT"C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ro 4 w: % RECSMMNDED LEVEL OF SERVICE ,.��,. .-�,,.y'z °t�: ' CONTRACTOR RATE Level ,> . Child Maintenance/Respite Age 0-10...$16.32/day County Basic Age 11-14...$18.05/day Maintenance Rate Age 15-21...$19.27/day + Respite Care$.66/day $19.73 1 +$.66 Respite Care ($20.39 day) $23.01 1 112 +$.66 Respite Care ($23.67 day) $26.30 2 +$.66 Respite Care ($26.96 day) $29.59 2 1/2 +$.66 Respite Care ($30.25 day) $32.88 3 - +$.66 Respite Care ($33.54day) $36.16 3 1/2 +$.66 Respite Care ($36.82 day) 4 $39.45 +$.66 Respite Care RCCF Drop Down ($40.11 day) $29.59 Assessment/Emergency V +$.66 Respite Care Rate ($30.25 day) Effective 7/01/2008 Exhibit"C"to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 72 THIS AGREEMENT is made and entered into this // day of CFune , 20 /41, of Weld County,and between the Board of County Commissionersy, 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 Mitchell & Shawna Eckhardt, 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 TeirJu ar a 9, a 01 y , to and until June 30, 2014, or until the Facility's certificate/lice/Ise 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 6/2013 67Ciy- /77*' II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 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 cific P P p procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 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 Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement,been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. 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 8 Revised 6/2013 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 ATTESTt/ 't1 of Human Services La By: i/i[ rte!C.. �L�! a_ met Deputy ' erk to the Bo rd :� .uglas 'ademacher, Chair it€1 1°k 0 JUN 1 1 2014 Are RACTOR: Approval as to Substance: f T i' WELD COUNTY DEPARTMI 'tchell & Shawna Eckhardt OF HUMAN SERVICES 505 54`h Ave Greeley, CO 80634 By: 14 By: /—V28 ty ty hector (or sig e s) irect is (or esignee's) Signature Si natur and D e and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 aoi 5�- /77r EXHIBIT "A" 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 Mitchell & Shawna Eckhardt, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in 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 on the Needs Based Care Rate Table, designated 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 each level of service, as indicated by the Needs Based Care Rate Table, designated 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 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit"A"to the CWS-7A 1 Revised 6/2013 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' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit"A"to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. 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. 11. 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. 12. 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. 13. 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. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. 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. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. 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. 18. 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. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. 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; C. 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; Exhibit"A"to the CWS-7A 3 Revised 6/2013 D. 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. E. 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. 22. 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. Exhibit"A"to the CWS-7A 4 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑l)One round trip a week 011/2)2 round trips a week ❑2)3-4 round trips a week. ❑2%)5 round trips a week 03)6 round trips a week ❑3%)7 round trips or more Comments: P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required O1)Once a month DM Two times month 02)Three times a month 02%)Once a week 03)Two times a week 03%)Three times a week or more Comments: P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? 0 Basic Maint.)No educational requirements 01)Less than a ''A hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 %) 1'/-2 hours per day 03)2'/-3 hours per day ❑3%)More that 3 hours per day Comments: _ P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1'%)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week 0 3)Constant basis during awake hours ❑3%)Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond aee appropriate needs with feeding,bathing,grooming, physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week D1)3 to 4 hours per week 011/2)5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3' )21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) On Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02'/z) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **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 Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) Dl)Less than 4 hours per month 02)4-8 hours per month 03)9-12 hours per month Exhibit"B"to the Additional Provisions 5 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a ly to this child. r ..[:'-'7...t: y �� Rating of GRmdir�iops; � i (Cheek one box for each ea(egory) . Y .bP� Y iT Assessment Areas Mild/ C moderatek Moderate q Orr'c• scsit .'. zx , ,, I . 1 1112 4•' Z Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ 0 ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ 0 0 Destructive of Property/Fire Setting 0 0 0 ❑ ❑ ❑ 0 Stealing ❑ 0 ❑ ❑ 0 0 ❑ I Self-injurious Behavior ❑ ❑ ❑ 0 0 0 ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ 0 Presence of Psychiatric Symptoms/Conditions 0 0 ❑ ❑ ❑ 0 ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ 0 ❑ Runaway ❑ ❑ D ❑ 0 0 ❑ Sexual Offenses ❑ 0 ❑ ❑ ❑ 0 ❑ Exhibit"B"to the Additional Provisions 6 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. t Rating of Conditions r t .. (Check one,box for each catega y) '"x ewe- 'I° -j+ Assessment Areas AMModerate) 13 L en NamMlli Moderate Moderate Balkugh Src < y, ie4 o 1 1 1/2 2 21/2 3 R- 31V2, . es S t,,x Inappropriate Sexual ICI ❑ ❑ CI ❑ Behavior Disruptive Behavior ❑ ❑ ❑ ❑ 0 ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ 0 0 Depressive-like Behavior ❑ El ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated ❑ 0 ❑ ❑ El ❑ El "severe',please complete the Medically fragile NBC) Emancipation ❑ 0 ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ O O O 0 0 ❑ Boundary Issues O ❑ ❑ ❑ ❑ ❑ 0 Requires Night Care ❑ ❑ ❑ ❑ ❑ 0 ❑ Education ❑ O ❑ ❑ ❑ ❑ 0 Involvement with Child's Family ❑ ❑ ❑ El 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'/ Exhibit"B"to the Additional Provisions 7 Revised 6/2013 EXHIBIT"C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE C1OAANIEN Y 4" LEVEL. . ICE ,? CO ACTO a :� P1 -P Level �" Mai ,ar R s deg Age 0-10...$16.32/day County Basic - Age 11-14...$18.05/day Maintenance Rate Age 15-21...$19.27/day +Respite Care$.66/day $19.73 1 +$.66 Respite Care ($20.39 day) $23.01 1 1/2 +$.66 Respite Care ($23.67 day) $26.30 2 +$.66 Respite Care ($26.96 day) $29.59 2 1/2 +$.66 Respite Care ($30.25 day) $32.88 3 +$.66 Respite Care ($33.54day) ss „., $36.16 3 1/2 -$. +$.66 Respite Care ($36.82 day) 4 $39.45 RCCF Drop Down 4.66 Respite Care ($40.11 day) $29.59 +$.66 Respite Care Assessment/Emergency ($30.25 day) Rate Effective 7/01/2008 Exhibit"C"to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT a THIS AGREEMENT is made and entered into this /1 day of \Tune , 20 /9', 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 Katie Egbert, 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: 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 February 22,2014, to and until June 30, 2014, 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 6/2013 O2©/4/-/77 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 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 Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 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 public transactions (federal, state, and local)terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. 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 8 Revised 6/2013 • 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: G �C�o V Human Services By: I,i,d.[ •i� n :� �a.'— • top e Deputy I/erk to the B Doug as Rademacher, Chairman ►'TRACTOR: JUN 1 1 2014 Approval as to Substance: WELD COUNTY DEPARTMENT Katie Egbert OF HUMAN SERVICES 214 14th Street SE Auburn, A 98002 By: my Director (orsigyps Director's (or desig e's) Signature i natur and D to and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 021,1 1/— /779 4 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this // day of p'i(/pe , 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 Richard & Marlaena Hartness, whose address is 15716 CR 40, Platteville, CO 80651, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster 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 ,132c lap /4 „a00/y , to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 aPO/$6— II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 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 Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement,been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. 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 8 Revised 6/2013 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 Cdr L County,on behalf of the Weld County Department ATTEST: G td_ ___ of Human Services By'/l�!��d a ,.I/<< in ern ' �� '�� (° .r' Deputy Perk to the Bo. ; 4'�- out as Rademacher, Chairman JUN 1 1 2014 y:j►Yi. ' ACTOR: Approval as to Substance: WELD COUNTY DEPARTMENT - ``ichard& Marlaena Hartness OF HUMAN SERVICES 15716 CR40 t/ Platteville, CO 80651 6 By: '(By: N \ 61112ordegne s Director's (or designee's) Signature i nature and Dal and Date 9/ CWS-7A Individual Provider Contract 9 Revised 6/2013 o2O7$1-77 7S( EXHIBIT "A" 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 Richard & Marlaena Hartness, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in 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 on the Needs Based Care Rate Table, designated 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 each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1643348. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 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. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit"A"to the CWS-7A 1 Revised 6/2013 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' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit"A"to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. 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. 11. 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. 12. 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. 13. 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. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. 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. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. 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. 18. 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. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. 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; C. 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; Exhibit"A"to the CWS-7A 3 Revised 6/2013 D. 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. E. 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. 22. 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. Exhibit"A"to the CWS-7A 4 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? O Basic Maint.) Less than one round trip a week 01)One round trip a week ❑1'/2)2 round trips a week ❑2)3-4 round trips a week. ❑2'/i) 5 round trips a week 03)6 round trips a week ❑3%:)7 round trips or more Comments: P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 01)Once a month ❑1'/)Two times month 02)Three times a month ❑2'/:)Once a week 03)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O Basic Maint.)No educational requirements 01) Less than a '/:hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 %) l''/2-2 hours per day 03)2'/:-3 hours per day ❑3/)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed O1)Less than 5 hours per week ❑1%s)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond aue appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? O Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%:) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'%z)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/:)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/:)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **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 Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00)Not needed or provided by another source(i.e. Medicaid) ❑l) Less than 4 hours per month 02)4-8 hours per month 03)9-12 hours per month Exhibit"B"to the Additional Provisions 5 Revised 6/2013 • EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions . "r .e Ems, (Check one box for each category) ;4,p:,,I. Assessment Areal. ,:mut Moderate/ ` tl ti t . ' ' Wins m09 � Moderate, Moderate . � SA twill.:? �` 0 1 1 1/2 2 21/2 3 ' 311"1. ` "".-'9' ;; Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ 0 0 ❑ Verbal or Physical Threatening 0 0 0 0 0 0 ❑ Destructive of Property/Fire Setting ❑ El 0 ❑ ❑ 0 0 Stealing ❑ 0 ❑ ❑ ❑ ❑ 0 Self-injurious Behavior ❑ 0 ❑ 0 ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ 0 ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ 0 0 ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ 0 ❑ ❑ Runaway ❑ 0 ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ Exhibit"B"to the Additional Provisions 6 Revised 6/2013 EXHIBIT"B" • - WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. ‘y.0a Ws ." a r s � t ai . # of Conditions, if % a.., , ' (Cheek one box for each categp 4"a` sr)w it;%. x .;t s . r "�.,,. Assessment Areas ',`�- ' fr,'' Mild/ 1'4 :„..;;,1.2. t t' ,, s None ` njg Moderate, Mode f ilk 'w ' a r: s 'o „2` `i21/2 c - Inappropriate Sexual Behavior 0 ❑ ❑ ❑ ❑ ❑ 0 Disruptive Behavior ❑ ❑ 0 0 ❑ 0 0 Delinquent Behavior ❑ 0 ❑ ❑ 0 0 ❑ Depressive-like Behavior 0 ❑ ❑ ❑ ❑ ❑ 0 Medical Needs (If condition is rated ❑ 0 0 0 ❑ 0 ❑ "severe",please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ 0 0 ❑ ❑ 0 Boundary Issues ❑ 0 ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ 0 ❑ ❑ Education ❑ ❑ 0 0 ❑ ❑ 0 Involvement with Child's Family ❑ ❑ ❑ 0 ❑ 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑i ❑ 11/2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'/ Exhibit"B"to the Additional Provisions 7 Revised 6/2013 EXHIBIT"C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE RECOMMENDED LEVEL(4F SERVICE CONTRACTOR RATE 4;' Level Child Maintenance/Resaite Age 0-10...$16.32/day County Basic Age 11-14...$18.05/day Maintenance Rate Age 15-21...$19.27/day + Respite Care$.66/day $19.73 1 +$.66 Respite Care ($20.39 day) $23.01 1 1/2 +$.66 Respite Care ($23.67 day) $26.30 2 +$.66 Respite Care ($26.96 day) $29.59 2 1/2 +$.66 Respite Care ($30.25 day) $32.88 3 +$.66 Respite Care ($33.54day) $36.16 3 1/2 +$.66 Respite Care ($36.82 day) 4 $39.45 RCCF Drop Down +$.66 Respite Care ($40.11 day) . . .... $29.59 *$66 Respite Care Assessment/Emergency Rate ($30.25 day) Effective 7/01/2008 Exhibit"C"to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made and entered into this 11 day of 7wie , 20 /4f, 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 Jeremiah & Kasi Irwin, whose address is 4544 Sunshine Circle Loveland, CO 80538 hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the 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 041_ l y am/ , to and until June 30, 2014, 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 6/2013 at/46-/7752 II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 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 or damage to such personal items. responsibility for loss shall be released from p yg D. This Agreement is intended to be applied in conjunction with Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. Substantial failure to satisfy the scope of work shall he defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions include, but are not limited to, any one or more of the following: I. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 2. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by Contractor 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 8 Revised 6/2013 WHEREFOR , the parties have herein set their hands and attied their seals the day and date first written above. COUNTY: f The Board of County Commissioners of Weld 'l ;� County,on behalf of the Weld County Department Al 1'EST:C/ �` of Human Services j1J4v: L64* : 4bso.-1(oe r Deputy rk to the 4:w Do as Rademacher, Chairman JUN 1 1 2014 Ito Q 0,0 RACTOR: Approval as to Substance: � WELD COUNTY DEPAR ' '� •ah&Kasi Irwin OF HUMAN SERVICES ,� U V3 44 Sunshine Circle —1-77:----- Loveland, CO 80538 By:- i‘f B . �.�� 4'1 5c/4040oi4 unty irecto s for esi ee s) a for `,'r des '*?ay. •_.ature S• t " and to CWS-7A Individual Provider Contract 9 Revised 6f2013 C7o/ V- /77V EXHIBIT "A" 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 Jeremiah and Kasi Irwin, hereinafter referred to as, "Contractor." GENERAL PROVISIONS County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in 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 on the Needs Based Care Rate Table, designated 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 each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1644260. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit"A"to the CWS-7A 1 Revised 6/2013 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' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit"A"to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. 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. 11. 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. 12. 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. 13. 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. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. 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. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. 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. 18. 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. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. 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; C. 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; Exhibit"A"to the CWS-7A 3 Revised 6/2013 • D. 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. E. 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. 22. 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. Exhibit"A"to the CWS-7A 4 Revised 6/2013 EXHIBIT"B" • WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 01)One round trip a week ❑1%)2 round trips a week ❑2)3-4 round trips a week. 021/2) 5 round trips a week 03)6 round trips a week ❑3'/:) 7 round trips or more Comments: P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month ❑1%a)Two times month 02)Three times a month ❑2'/i)Once a week 03)Two times a week ❑3'/%)Three times a week or more Comments: P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? No educational requirements ❑1)Less than a ''/ hour per day 01%) 1/2 hour a day Basic Maint.) q 0 ' '/-2 hoursper day 03)2/z-3 hours per day ❑2) 1 hour a day 02 /:) 1 z ❑3'/) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.)No special involvement needed ❑l) Less than 5 hours per week 01%)5 to 7 hours per week 02) 8 to 10 hours per week ❑2' ) 11 to 14 hours per week 0 3)Constant basis during awake hours ❑3'%)Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming, physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1' ) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑31)21 or more hours per week Comments: A I. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1' ) Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑21) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. ❑31) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **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 Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00)Not needed or provided by another source(i.e. Medicaid) 01)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month Exhibit"B"to the Additional Provisions 5 Revised 6/2013 - - EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions (Check one box for each category) Mild/ _ Moderate/ Assessment Areas ts Noae had Moderate. Moderate ' f_ei h i b ., Severe immen 0 1 1 1/2 2 2 1/2 3 3 1/2 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ O ❑ O O ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ ❑ O O Self-injurious Behavior O O ❑ Cl O O O Substance Abuse ❑ ❑ ❑ ❑ ❑ O O Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ O ❑ ❑ Enuresis/Encopresis ❑ O O O ❑ O O Runaway ❑ ❑ ❑ El ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ O O O O Exhibit"B"to the Additional Provisions 6 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Conditions (Check one box for each category) Assessment Areas Mild/ Moderate/ Ham( '`""' None nlil Moderate. Moderate nigh High &m a, -contents 0 1 11/2 2 21/2 3 . 31/2``'I' 'O '; Inappropriate Sexual ❑ ❑ 0 0 ❑ ❑ ❑ Behavior Disruptive Behavior ❑ 0 ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior 0 ❑ ❑ ❑ 0 0 ❑ Medical Needs (If condition is rated ❑ ❑ ❑ ❑ ❑ ❑ ❑ "severe',please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ 0 0 Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1%2 ❑ 2 ❑ 2'/2 ❑ 3 ❑ 31/2 Exhibit"B"to the Additional Provisions 7 Revised 6/2013 EXHIBIT"C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE RECOMMENDED LEVEL OF SERVICE - CONTRACTOR RATE • Pi.-:P5 Level Geld Majtnan1 d Respite Age 0-10...$16.32/day County Basic Age 11-14...$18.05/day Maintenance Rate Age 15-21...$19.27/day + Respite Care$.66/day $19.73 1 +$.66 Respite Care ($20.39 day) $23.01 1 1/2 +$.66 Respite Care ($23.67 day) $26.30 2 +$.66 Respite Care ($26.96 day) $29.59 2 1/2 +$.66 Respite Care ($30.25 day) $32.88 3 +$,66 Respite Care ($33.54day) $36.16 31/2 +$.66 Respite Care ($36.82 day) 4 $39.45 +$.66 Respite Care RCCF Drop Down ($40.11 day) $29.59 +$ Respite Care Assessment/Emergency . $ ( 30.25 day) Rate ($ Effective 7/01/2008 Exhibit"C"to the Additional Provisions 8 Revised 6/2013 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT Lit '/ THIS AGREEMENT is made and entered into this // day of \T an e , 20/7 , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and Drew White & Amber Johansen, whose address is 2405 13th Ave, 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 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 jcilie, ciy ,?0/3 , to and until June 30, 2014, 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 6/2013 a9/y- /77y II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 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 Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. 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 8 Revised 6/2013 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 i A(S. / .�CLto��,C of Human Services 13 La I By: ii/i _! ��•�_� .i/� V • • �.. l Deputy 'erk to the Boa ~ ougl.s Rademacher, Chairman 11.61 .¶ry9J - .i JUN 1 1 2014 CTOR: Approval as to Substance: Cf '�..:r' WELD COUNTY DEPARTMENT y !Ir./ White & Amber Johansen OF HUMAN SERVICES 2405 13th Ave Greeley CO. 80631 1 By: � l4 By: my rector (or sign e' ) Dir or's (or desig ee's) Signature natur and D e and We CWS-7A Individual Provider Contract 9 Revised 6/2013 d0/V— /779 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT a THIS AGREEMENT is made and entered into this 11 day of Cane , 20 /9, 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 Heidi & Kevin Johnson, whose address is 39343 Boulevard D, Eaton, CO 80615, hereinafter referred to as, "Contractor." This Agreement covers all children placed by County with Contractor. WITNESSETH: WHEREAS, the Colorado State Department of Human Services (hereinafter referred to as "State Department"), has certified or licensed Contractor's facility as a Family Foster Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and WHEREAS, Contractor understands and agrees that it must, during the term hereof, hold a valid certificate/license for the Facility, maintain certification standards, and read and be fully familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State Department, and WHEREAS, County may, but shall not be obligated to, purchase foster care services, and the County or any duly authorized agent may request such services to be provided to any child at any time within the limits of the Facility's certificate/license and without prior notice. NOW, THEREFORE, in consideration of the mutual promises and covenants made herein, County and Contractor agree as follows: I. TERM: A. The term of this Agreement shall be from At e; 3 c90)y , to and until June 30,2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 o7P/i/— /77y II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 • 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 Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. 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 8 Revised 6/2013 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 �( S< ca • h County, on behalf of the Weld County Department ATTEST. G ` _ Q`s of Human Services Silaz By: 1/42 l92-(•• Deputy erk to the Douglas Rademacher, Chairman JUN 1 1 2014 O NTRACTOR: Approval as to Substance: _ '"`' WELD COUNTY DEPARTMENT Heidi & Kevin Johnson OF HUMAN SERVICES 39343 Boulevard D. Eaton, CO 80615 f. ^ By 2$ ( By: 0,4/36 1 sIaII4 ounty Direc 's (or designee's) Direc o 's (or designee's) Signature ignature and Date and Date'tell°, 6ppoiLt CWS-7A Individual Provider Contract 9 Revised 6/2013 4t0/ -771 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT yy- THIS AGREEMENT is made and entered into this 1/ ay of ptiM8 , 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 Michael & Hava Smith,whose address is 1117Alpine 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. 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 januon j 3) 0201`/ , to and until June 30, 2014, or until the Facility's certificate/licerlse is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 ao/Y-/779. II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 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 Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. 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 8 Revised 6/2013 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: . Board of County Commissioners of Weld adt& > 'i?t�' , on behalf of the Weld County Department ATTEST:' r .,.o d ti n Services sass i By: �i///,/ / �� A' ;. �� 1,��_,• Deputy t erk to the Boar QI 14 ',Douglas Rademacher, Chair JUN 1 1 2014 CONTRACTOR: Approval as to Substance: WELD COUNTY DEPARTMENT Michael & Hava Simmons OF HUMAN SERVICES 1117 Alpine CT Windsor, CO 80550 j3 I/ im By: Y By: '; t,vc_t tb4unty irect s ( desi e's) Director's (jx41v1A/L/te designee's) Signature natur and ate and Date CWS-7A Individual Provider Contract 9 Revised 6/2013 &t/S'—/77 ' EXHIBIT "A" 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 Michael & Hava Simmons, hereinafter referred to as, "Contractor." GENERAL PROVISIONS 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in 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 on the Needs Based Care Rate Table, designated 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 each level of service, as indicated by the Needs Based Care Rate Table, designated 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 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit"A" to the CWS-7A 1 Revised 6/2013 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' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit"A"to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. 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. 11. 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. 12. 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. 13. 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. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. 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. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. 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. 18. 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. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. 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; C. 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; Exhibit"A"to the CWS-7A 3 Revised 6/2013 D. 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. E. 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. 22. 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. Exhibit"A"to the CWS-7A 4 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P I. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑1)One round trip a week ❑1'/z)2 round trips a week ❑2) 3-4 round trips a week. ❑2'/:) 5 round trips a week 03)6 round trips a week ❑3%z)7 round trips or more Comments: P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 01)Once a month ❑1' )Two times month 02)Three times a month ❑2'/)Once a week 93)Two times a week ❑3'/)Three times a week or more Comments: P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? 0 Basic Maint.)No educational requirements ❑1) Less than a '/z hour per day 011/2) 1/2 hour a day 02) I hour a day 02 %) 11/4-2 hours per day 03)2'/z-3 hours per day ❑3'/) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.)No special involvement needed 01) Less than 5 hours per week ❑1'/z)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2`/z) 11 to 14 hours per week ❑ 3)Constant basis during awake hours ❑3%)Nighttime hours Comments: _ P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? O Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/z)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) I 1 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week Comments: A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/z)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2/) Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **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 Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month Exhibit"B"to the Additional Provisions 5 Revised 6/2013 m EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. . Rating'of Conditions (Check one box for each category) w'�` ; a..,,,47,,,,; :..... .? Assessment Areas Mild/ Moderate! i ' &at Moderate. ModeraEe z ;EGQh Mb" '� ,.Severe 44" 31/2 O7. :, 0 1 1 1/2 2 2 1/2 3 u is- Aggression/Cruelty to Animals ❑ O O ❑ O O O Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ O O Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ El O O Stealing ❑ O O ❑ O O ❑ Self-injurious Behavior ❑ O O O O O O Substance Abuse ❑ O O O O ❑ O Presence of Psychiatric Symptoms/Conditions ❑ ❑ O ❑ O O O Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ O O Runaway ❑ O O O O O ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ O 0 I Exhibit"B"to the Additional Provisions 6 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child. p r. Rating of Conditions Yy,, $ I . ,,,. (Check one box for each category) ,4,.";.,,1 K. <s Assessment Areas m Moderate/ ,« None � Moderate. Moderate High Hieh er Ci;me�t9 �" 0 1 11/2 2 21/2 3 112 _ Inappropriate Sexual ❑ ❑ ❑ ❑ ❑ 0 0 Behavior ' Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ 0 ❑ ❑ 0 ❑ ❑ Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated 0 ❑ ❑ 0 ❑ ❑ 0 "severe",please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ 0 Eating Problems ❑ 0 ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ 0 Requires Night Care ❑ 0 0 0 ❑ ❑ ❑ Education ❑ 0 0 ❑ ❑ 0 ❑ I Involvement with Child's Family 0 ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 21/2 ❑ 3 ❑ 3'A Exhibit"B"to the Additional Provisions 7 Revised 6/2013 EXHIBIT"C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE RECOMMENDED LEVEL OF SERVICE CONTRACTOR RATE PI -P5 Level Child Maintenance/Respite Age 0-10. .$16.32/day County Basic Age 11-14...$18.05/day Maintenance Rate Age 15-21...$19.27/day + Respite Care$.66/day $19.73 1 +$.66 Respite Care ($20.39 day) $23.01 1 1/2 +$.66 Respite Care ($23.67 day) $26.30 $ Re spite+ Res.66 ite Care ($26.96 day) $29.59 21/2 +$.66 Respite Care ($30.25 day) $32.88 3 +$,66 Respite Care ($33.54day) $36.16 31/2 +$.66 Respite Care ($36.82 day) 4 $39.45 +$.66 Respite Care RCCF Drop Down ($40.11 day) $29.59 AssessmenVEmergency +$.66 Respite Care Rate ($30.25 day) Effective 7/01/2008 Exhibit"C"to the Additional Provisions 8 Revised 6/2013 V INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT a THIS AGREEMENT is made and entered into this day of akn e , 20/9, 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 Stepanie Smith & Mark Pults, whose address is 25 Yukon Street, Lakewood, CO 80226, 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 XA.Aua,,,/ o?9, ,,?o/z/, to and until June 30, 2014, or until the Facility's certificate/license is revoked or suspended. B. Each party shall have the right to terminate this Agreement by giving the other party written notice received at least thirty (30) days prior to the intended date of termination. If notice is so given, this Agreement shall terminate upon the expiration of thirty (30) days, or until the eligible child(ren) may be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease; however, the parties shall not be released from the duty to perform their obligations up to the date of termination. CWS-7A Individual Provider Contract 1 Revised 6/2013 a6/*— /77 ' II. AGREEMENTS OF THE PARTIES: A. Contractor agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 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. CWS-7A Individual Provider Contract 2 Revised 6/2013 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 6/2013 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 $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 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. CWS-7A Individual Provider Contract 4 Revised 6/2013 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. C. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. CWS-7A Individual Provider Contract 5 Revised 6/2013 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 Exhibits A, B, and C 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 and Exhibits A, B, and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and C are intended to be in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. E. The State of Colorado Department of Human Services shall be and hereby is permitted to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other Agreements as deemed necessary. Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. F. County shall have access to Contractor's financial records as they relate to this Agreement for purposes of audit. Such records shall be complete and available for audit 90 days after final payment hereunder and shall be retained and available for audit purposes for at least five years after final payment hereunder. CWS-7A Individual Provider Contract 6 Revised 6/2013 G. Time is of the essence in each and all of the provisions of this Agreement. H. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. I. Any notice required to be given under this Agreement shall be in writing and shall be mailed or delivered to the other party at that party's address as stated above. J. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado and be in accordance with the policies, procedures, and practices of County. K. This Agreement is nonexclusive and County may engage or use other contractors or persons to perform services of the same or similar nature. L. Contractor certifies that Contractor is not an illegal immigrant, and further, Contractor represents, warrants, and agrees that it has verified that Contractor does not employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and Contractor may be held liable for damages. M. Contractor assures and certifies that it and its principals: 1. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. 2. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. 4. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local)terminated for cause or default. CWS-7A Individual Provider Contract 7 Revised 6/2013 N. In addition to terminating this Agreement, in accordance with the provisions of Section I., above, County may exercise the following remedial actions County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement and Exhibits A and B. 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 8 Revised 6/2013 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 �jja/{A)ATTEST: .l (pac of Human Services 1 By. Deputy 'lerktothe Boa!i R �0 1as Ra:emacher, Chair AO �� • �.. JUN 1 1 2014 i` �� • CTOR: Approval as to Substance: �C Pip WELD COUNTY DEPARTMENT 7- epanie Smith & Mark Pultz OF HUMAN SERVICES 25 Yukon Street Lakewood, CO 80226 By: /y B : P tikucrlfT ''tt I-29 - Iy unty D rector (or d ign e s) ir tor's (or designee's) Signature Si nature and D e and D� CWS-7A Individual Provider Contract 9 Revised 6/2013 EXHIBIT "A" 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 Stephanie Smith & Mark Pultz, hereinafter referred to as, "Contractor." GENERAL PROVISIONS I. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor unless the child is placed in a County certified kinship foster care home or if the child is placed in 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 on the Needs Based Care Rate Table, designated 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 each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1645696. 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 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Contractor. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4`1' of each month following the month of service. If the reimbursement request is not submitted within twenty-five(25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. Exhibit"A"to the CWS-7A 1 Revised 6/2013 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' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. Exhibit"A"to the CWS-7A 2 Revised 6/2013 CONTRACTOR SHALL: 10. 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. 11. 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. 12. 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. 13. 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. 14. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 15. 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. 16. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 17. 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. 18. 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. 19. Maintain/update medication logs on a daily basis, if child is taking medications. 20. Maintain behavior observation notes as required by the level of care assessed for each child. 21. 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; C. 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; Exhibit"A"to the CWS-7A 3 Revised 6/2013 D. 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. E. 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. 22. 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. Exhibit"A"to the CWS-7A 4 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ['Basic Maint.)Less than one round trip a week El)One round trip a week 01%)2 round trips a week ❑2)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week 03%)7 round trips or more Comments: P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions? O Basic Maint.)No participation required 01)Once a month ❑1'%)Two times month 02)Three times a month 02%)Once a week 03)Two times a week 03%)Three times a week or more Comments: P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a ''/z hour per day 01%) 1/2 hour a day ❑2) I hour a day ❑2 %) 1'/z-2 hours per day 03)2'/z-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1%z) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the Contractor required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week Comments: A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3)Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **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 Contractor. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00)Not needed or provided by another source(i.e. Medicaid) 01)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month Exhibit"B"to the Additional Provisions 5 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Rating of Condition r ' `'" tu€t ° B n 1 rtf t; (Check one box for each category) , %. Assessment Areas Eac Moderate/ -, [ {7,,t,,,,,/ ne MN Moderate, Moderate g�4 1 4 G.IM a M11111 I b 1 1 1/2 2 21/2 3 '. 3 j ' ° s z 4 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ 0 0 ❑ Verbal or Physical Threatening ❑ 0 ❑ ❑ 0 0 ❑ Destructive of Property/Fire Setting ❑ ❑ 0 0 0 0 0 Stealing ❑ ❑ 0 0 0 0 0 Self-injurious Behavior ❑ ❑ 0 ❑ ❑ ❑ 0 Substance Abuse ❑ ❑ 0 ❑ ❑ ❑ 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ 0 Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ 0 ❑ ❑ 0 ❑ ❑ Exhibit"B"to the Additional Provisions 6 Revised 6/2013 EXHIBIT"B" WELD COUNTY DEPARTMENT OF HUMANS SERVICES NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child r v .,! lx Ratinpof Conditions 4:4''',-,-, (Check one box for each catego `' 1."`n Assessment Areas Moderatd ; 'k >14‘ "} Naas Mild Moderate, Modern; _ nag Thai ata 0 1 1112 2 21/2 3 -3112 ti Inappropriate Sexual ❑ ❑ ❑ ❑ ❑ ❑ ❑ Behavior Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated 0 ❑ 0 0 0 ❑ ❑ "severe",please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 0 0 Eating Problems O 0 0 0 ❑ 0 0 Boundary Issues O 0 0 O 0 0 0 Requires Night Care O 0 0 0 0 0 0 Education ❑ 0 0 0 ❑ 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1 Yz ❑ 2 ❑ 2''/ ❑ 3 ❑ 3'/ Exhibit"B"to the Additional Provisions 7 Revised 6/2013 EXHIBIT"C" WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE REOMMEW L OF SERVI t 2 CONTRACT N � <Level ghild Maintenan Age 0-10...$16.32/day County Basic Age 11-14...$18.05/day Maintenance Rate Age 15-21...$19.27/day + Respite Care$.66/day $19.73 1 +$.66 Respite Care ($20.39 day) $23.01 1 1/2 +$.66 Respite Care ;.. ($23.67 day) $26.30 2 +$.66 Respite Care ($26.96 day) $29.59 2 1/2r' +$.66 Respite Care £t1' ($30.25 day) $32.88 3 +$.66 Respite Care ($33.54day) $36.16 3 1/2 +$.66 Respite Care i4 ($36.82 day) $39.45 4 +$.66 Respite Care RCCF Drop Down ($40.11 day) $29.59 +$.66 Respite Care Assessment/Emergency ($30.25 day) Rate Effective 7/01/2008 Exhibit"C"to the Additional Provisions 8 Revised 6/2013 Hello