HomeMy WebLinkAbout20123129.tiff MEMORANDUM
1861
DATE: November 1, 2012
1� rl
TO: Sean P. Conway, Chair, Board of Coun Commissio rs
G p U N T I FROM: Judy A. Griego, Director, Human Se t �d s e m
RE: Individual Provider Contracts for Purpose of Foster Care
Services and Foster Care Facility Agreements and the
Weld County Addendums to the Agreements 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 Agreements and the Weld County Addendums to the
Agreements between the Department and Various Providers. These Agreements were
reviewed under the Board's Pass-Around Memorandum dated August 8, 2012, and October
24, 2012, and approved for placement on the Board's Consent Agenda.
The major provisions for these Agreements are as follows:
No. Provider/Term Facility Type/Location
1 Castillo, Arturo and Elsa Foster Home
July 1, 2012—June 30, 2013 Fort Lupton, Colorado
2 Means, Nathan and Lisa Foster Home
July 1, 2012—June 30, 2013 Greeley, Colorado
3 Guilbert, Jonathan and Jeanine Foster Home
September 20, 2012—June 30, 2013 Keenesburg, Colorado
4 Land, Brad and Molly Foster Home
October 11, 2012—June 30, 2013 Greeley, Colorado
If you have questions, please give me a call at extension 6510.
2012-3129
�i.7 �9-
I -) iZO &! .'/?/S,L) d 11
//- 5 - vve?
(-WS-/A (KIU-IU/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, C//2 O�i z- by and between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Castillo, Arturo and Elsa, Provider ID#1592544, 905 Greenwood Ct., Fort Lupton, CO 80621,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2012 and continue in force until
June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. 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.
The Provider 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.
1
LWJ-/A(Klu-lu/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
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.
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.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
4. To give the provider a written record of the child's admission to the home at the time of
placement.
2
LWJ-/A(KIU-I(1/99)
•
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.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the - "_ WELD COUNTY BOARD OF SOCIAL
ae., ♦,�� \:La% SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
k452
( 1b6 1 U ,
Deput IerI(to the Body'/( .27 Chair Signature
Approval as to Substance: PROVIDER
NOV 0 5 2012
WELD COUNTY DEPARTMENT Castillo, Arturo and Elsa
OF HUMAN SERVICES 905 Greenwood Ct.
Fort Lupton, CO 80621 By: By: r k- u l l//6: rA g &
irector' Signatur /Date Provider's Signature/Date
By: E i c Ct �, (cA
Provider's Signature/Date
3 3i
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Castillo, Arturo and Elsa
and the
Weld County Department of Human Services
for the period from July 1, 2012 through June 30, 2013.
c__
The following provisions, made this dab day of , 2012, are added to the referenced
Agreement. Except as modified hereby, all terms of e Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider 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 Provider 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 Provider 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#1592544. 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 Provider.
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.
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
L. but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Provider will arrange reimbursement through Medicaid.
Any other special requests for transportation reimbursement shall require prior
approval by the Service Utilization Unit 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 Provider 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 Provider 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 Provider 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 Provider
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 Provider 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 Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider 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 Provider, 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'
2 Weld County Addendum to the CWS-7A
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
3 Weld County Addendum to the CWS-7A
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Exhibit B)
WELD COUNTY OHS
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 provider 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%n)5 round trips a week ❑3)6 round trips a week
❑3'/:) 7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month DI%)Two times month
❑2)Three times a month ❑2'/x)Once a week ❑3)Two times a week
❑3'/)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular of
special education plan?
❑ Basic Maint.)No educational requirements ❑I) Less than a '/,hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 %) I'/:-2 hours per day ❑3)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 provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑I)Less than 5 hours per week ❑1'/)5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2%) I I to 14 hours per week
❑3)Constant basis during awake hours ❑3%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin
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 ❑2/) I I to 15 hours per week ❑3) 16 to 20 per week
❑3'/a)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.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
01%) 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 provider.
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
5 Weld County Addendum to the CWS-
• (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
I atw onditt atC
ti r� ' @' '"r I. n { x `+ �, t ,.._. cxni ' ' t, st'., E
a 't Wg ,X'CBC�I G8g �( `� N "' a
6reas z: t,u k '.` "s �s n tk
Fti " ederµ liti �
r.: : ��r µ3�, � t
o, tt u 1 .. X 1/2 q, Fl t t o tC}y 3.
Aggression/Cruelty to
Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑
Verbal or Physical
Threatening 0 ❑ ❑ ❑ ❑ 0 ❑
Destructive of
Property/Fire Setting 0 0 ❑ ❑ ❑ ❑ ❑
Stealing
❑ ❑ 0 ❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑ ❑ ❑ 0
Substance Abuse
❑ ❑ ❑ ❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0 ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑ El ❑ ❑
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-
(Exhibit B)
WELD COUNTY DHS
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 ti
railiT
r ' (>L�t ` .one box for each ti r� S ?. LSn`
; .. ro��{ rti�
'.' 6Rs ': , a. ,. ,9 a ?2.'Y gl7 tur.t1; ,45t— 146.a+ xuit
44 l
tl y
tt t gdgqerxtt,. : Moderate Tai
lk 1 /2. 2 21 r , x
Inappropriate Sexual
Behavior 0 ❑ 0 0 ❑ ❑ 0
Disruptive Behavior
❑ 0 ❑ ❑ 0 ❑ ❑
Delinquent Behavior
❑ 0 ❑ 0 ❑ ❑ 0
Depressive-like Behavior
❑ 0 ❑ 0 0 ❑ 0
Medical Needs
(If condition is rated-severe'', 0 0 0 ❑ ❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ 0 0 ❑ ❑
Eating Problems
❑ 0 ❑ ❑ ❑ ❑ 0
Boundary Issues
❑ ❑ 0 ❑ ❑ ❑ ❑
Requires Night Care
❑ 0 ❑ ❑ ❑ ❑ ❑
Education
❑ ❑ 0 ❑ ❑ ❑ 0
Involvement with Child's
Family ❑ ❑ ❑ ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2'h ❑ 3 ❑ 3'h
7 Weld County Addendum to the CWS-
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
,t 5M yt4 1 y
aJa r`i
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-
.
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Wet CountyC -rk�r�t+tu :�: d WELD COUNTY BOARD OF SOCIAL
\stfIPMAA• hJ�Mi17601 r. I /a SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
q�at SERVICES
%6I V +.
By' 1 'i'/l<, i �� •°�'��Va A By:
P
Depu Clerk to the ► a. +' - Chair Signature
NOV 0 5 2012
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Castillo, Arturo and Elsa
OF HUMAN SERVICES 905 Greenwood Ct.
Fort Lupton, CO 80621
By: By:A 7`o r 0 (106,5447
Co ty ire tor's Sign ture/D e Provider's Signature/Date
By: l/a
Provider's Signature/Date
&tv,2- SAR
9 Weld County Addendum to the CWS-7A
LW -/A (K I U-I U/99)
•
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT l®�1
ire
1. THIS CONTRACT AND AGREEMENT, made this date, cepleahens74o?mz_by and bet wee
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of /.
the Weld County Department of Human Services, hereinafter called "County Department" and,
Means, Nathan and Lisa, Provider ID#1601788, 2632 15th Ave, Greeley, CO 80631,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2012 and continue in force until
June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. 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.
The Provider 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.
1
(K10-10/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
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.
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.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
4. To give the provider a written record of the child's admission to the home at the time of
placement.
2
LWJ-/A (KIU-IU/99)
• 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.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
I�q �SERVICES, ON BEHALF OF THE WELD
- •I'4 �a OUNTY RVICES DEPARTMENT OF HUMAN
o mil
By: I1lf .A._ a. ' •
Depu Clerk to the Boa � OR41 Chair Signature
11,
Approval as to Substance: v -� PROVIDER NOV 0 5 2012
WELD COUNTY DEPARTMENT Means, Nathan and Lisa
OF HUMAN SERVICES 2632 15th Ave
Greeley, CO 80631
By: By: q.z>
Director's Signatu /Date Provider's Signature/Date
By: 711714•61 tl -77-IZ
Provider's Signature/Date
3
•
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Means, Nathan and Lisa
and the
Weld County Department of Human Services
for the period from July 1, 2012 through June 30, 2013.
The following provisions, made this ,7-7 day of f e.2 , 2012, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider 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 Provider 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 Provider 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#1601788. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 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 Provider.
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.
t Weld County Addendum to the CWS-7A
C. • Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Provider will arrange reimbursement through Medicaid.
Any other special requests for transportation reimbursement shall require prior
approval by the Service Utilization Unit 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 Provider 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 Provider 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 Provider 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 Provider
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 Provider 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 Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider 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 Provider, 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'
2 Weld County Addendum to the CWS-7A
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
3 Weld County Addendum to the CWS-7A
• violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
. C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Exhibit B)
•
• WELD COUNTY DHS
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 provider 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 ❑3)6 round trips a week
03%) 7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month ❑1'/:)Two times month
❑2)Three times a month 02%)Once a week 03)Two times a week
❑3/)Three times a week or more
Comments:
P 3. How much time is the provider 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'/a) %z hour a day
❑2) 1 hour a day 02 ''/:) I'h-2 hours per day 03)2'/s-3 hours per day
❑3'/z) More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑I)Less than 5 hours per week ❑1%:)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) 1 I to 14 hours per week
❑3)Constant basis during awake hours ❑3%:)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with reedit];
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week 01)3 to 4 hours per week 011/2)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2' ) 1 I 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.
❑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 provider.
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
5 Weld County Addendum to the CWS-7
•
(Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE
' BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Of v,,,, .,Ml Ear„, r k,l
r ' +, a (Check one, for each categoryl f ' § lt: i 7z� k.: ' x" to
4 _ R E isxd 'R, }y &",in
n �� x.. i x T.°„ §, r.e. m 8 d ° §tartitift3�miligsial �. s `
tE§ ' /tr Mod 'v`D a
'v 2 2 i oirl� !i 14.O3 a, dyd
Aggression/Cruelty to
Animals 0 0 0 0 0 0 0
Verbal or Physical
Threatening 0 0 0 0 0 0 0
Destructive of
Property/Fire Setting 0 0 0 0 El 0 0
Stealing
❑ 0 0 ❑ 0 0 0
Self-injurious Behavior
❑ 0 0 0 0 0 0
Substance Abuse
❑ 0 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions 0 0 0 0 0 0 0
Enuresis/Encopresis
❑ 0 0 0 ❑ 0 0
Runaway
❑ 0 0 0 0 0 0
Sexual Offenses
❑ 0 0 0 0 0 0
6 Weld County Addendum to the CWS-7
(Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child
f i r L k S ry ( - t U xia { simpqe.,
fi r° y a r x m A.- '` �, (Check oFI '&for each "°�, �., ,", %,, tr"it F L
s" t s r a ,, kL v *
i>� {y�� —O.''.t.'-'---.A.-JPs °p t {' t
i,ut ti f t N,„ P riti J 6 2I 5 ' qt a:-
F c i�^'4 2 X 30 pi i 4t� tEl-, t Ii
jr y i{E ♦ {C .
.. .C'... w.t.; tl �... l₹ Z ink` �r iii d t _..::f i gali en `�' p`
Inappropriate Sexual
Behavior 0 ❑ 0 0 0 ❑ 0
Disruptive Behavior
❑ 0 ❑ 0 ❑ 0 0
Delinquent Behavior
❑ 0 0 ❑ ❑ ❑ ❑
Depressive-like Behavior
❑ 0 ❑ 0 0 0 ❑
Medical Needs
(If condition is rated"severe", ❑ ❑ ❑ 0
❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ 0 ❑ 0 0 0
Eating Problems
❑ 0 0 ❑ ❑ 0 0
Boundary Issues
❑ ❑ ❑ 0 0 ❑ ❑
Requires Night Care
❑ 0 0 ❑ 0 0 ❑
Education
❑ 0 0 ❑ 0 ❑ ❑
Involvement with Child's
Family 0 ❑ ❑ ❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'z ❑ 3 ❑ 3'/
7 Weld County Addendum to the CWS-7
S-7
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
�. PRRCPMM�D z
4 t oO e fi
ti.
t � � i'n i e att
/+,:i1.i{'"�P $
..102141)
Age 0-10 $16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$,66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
vi
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-7
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
nYVA.Ad. A_ SERVICES, ON BEHALF OF THE WELD
,, La COUNTY DEPARTMENT OF HUMAN
SERVICES
By: a By P
Deputy " lerk to the B ctsieCC Chair Signature
NOV 0 5 2
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Means,Nathan and Lisa
OF HUMAN SERVICES 2632 15th Ave
Greeley, CO 80631
By: By: ,n,,...-. 9-1'?
Coin t Director s Signatu e/Data' Provider's Signature/Date
By: .Vi al a12 cj,2 /-1 L
Provider's Signature/Date
0,2C/02 -3/2
9 Weld County Addendum to the CWS-7A
I,WJ-/A (KIU-IU/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, 5ee?LtMh 0.V by and between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Jonathan &Jeanine Guilbert, 1621214, 230 S. Dickson St, Keenesburg, CO 80643,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from September 20, 2012 and continue in force
until June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. 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.
The Provider 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.
1
21/ 7 3/2 7
CWS-7A (I{10-10/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
• placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
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.
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.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
4. To give the provider a written record of the child's admission to the home at the time of
placement.
2
CWS-7A (KIU-IU/99)
• • 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.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to thg B`y.s WELD COUNTY BOARD OF SOCIAL
A+ `. L SERVICES, ON BEHALF OF THE WELD
nfaibM1A40
,�0�� �I COUNTY DEPARTMENT OF HUMAN
SERVICES
1/421
By: f4' s ( ,��' ':r .•
B♦� + A By:
Depu, Clefk to the B.4y Chair Signature
% (:. MN 05212
Approval as to Substance: � PROVIDER
WELD COUNTY DEPARTMENT JONATHAN & JEANINE GUILBERT
OF HUMAN SERVICES 230 S. DICKSON STREET
KEENESBURG, CO 80643
•
By:
41,V
ect4oig( Date t` rovider'shture/Date
•
By Provider's Signature/Date
3
,/r/i2-3/72/c-
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
JONATHAN & JEANINE GUILBERT
and the
Weld County Department of Human Services
for the period from :p/%fdc 2ol;( through June 30, 2013.
The following provisions, made this fit) day of 1 ep/3fider, 2012, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider 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 Provider 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 Provider 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#1621214. 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 Provider.
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.
,mil/ - 3L22
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Provider will arrange reimbursement through Medicaid.
Any other special requests for transportation reimbursement shall require prior
approval by the Service Utilization Unit 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 Provider 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 Provider 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 Provider 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 Provider
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 Provider 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 Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider 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 Provider, 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'
2 Weld County Addendum to the CWS-7A
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
3 Weld County Addendum to the CWS-7A
• violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Exhibit B)
WELD COUNTY DHS
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 provider 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 ❑19:)2 round trips a week
❑2)3-4 round trips a week. 02%) 5 round trips a week ❑3)6 round trips a week
❑3%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
0 Basic Maint.)No participation required ❑1)Once a month ❑1%a)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3'A)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular o
special education plan?
0 Basic Maint.)No educational requirements 01) Less than a ''/2 hour per day ❑I'/) '/e hour a day
❑2) 1 hour a day 02 %) 11/2-2 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 provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed 01) Less than 5 hours per week ❑1'/n)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 ❑3%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedi.
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week ❑1'/2) 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%)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.)
❑1)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.
❑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.
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 provider.
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) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the CW5
• (Exhibit B)
WELD COUNTY DHS
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 x.h
(Check one box for each category)
Assessment Areas E oderate/ MA isir'
None Mild Moderate. Moderate High Ai2h severt (K nments:
0 1 1 1/2 2 2 1/2 3 3 1/2
Aggression/Cruelty to
Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑
Verbal or Physical
Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑
Destructive of
Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑ ❑ O O
Self-injurious Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑ ❑ O O
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ El ❑ O ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ O ❑ ❑ El ❑ ❑
6 Weld County Addendum to the CWS
•
• (Exhibit B)
WELD COUNTY DHS
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/ High/
None hffil Moderate. Moderate nigh Ahab Sever Comments.Tr
0 1 11/2 , 2 21/2 3 31/2
Inappropriate Sexual
Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ 0 ❑
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ ❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues
❑ 0 0 ❑ ❑ ❑ El
Requires Night Care
Cl ❑ ❑ ❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
Involvement with Child's
Family ❑ ❑ ❑ ❑ El ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) in 0 ❑1 ❑ 1 Y2 2 n 2'/ ❑ 3 ❑ 3'A
7 Weld County Addendum to the CW5
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
RECOMMENDED
LEVEL OF SERVICE PROVIDER RATE
PI - P5
Level Rate
Age 0-10. .$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$,66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
+$.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
\sintVA • SERVICES, ON BEHALF OF THE WELD
� ''^ ✓� . ((e COUNTY DEPARTMENT OF HUMAN
SERVICES
1/42
11.6
Deput ' ler to their re urc, Chair Signature
✓ NOV 0 5 2012
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Jonathan & Jeanine Guilbert
OF HUMAN SERVICES 230 S. Dickson Street
Keenesburg, CO 80643
By: By:, , aaac-ieLl ,`L `1A
Co Directo 's Signal re/Dat •Provider's Signature/Date
i
By: `
rovider's Signature/Date
9 Weld County Addendum to the CWS-7A
UN/S-7A (RIO-10/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, U'Gic/k'J.'r l) ,/0)9Z by and between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Brad & Molly Land, 1543324, 1831 25th Ave, Greeley, CO 80634 , hereinafter called "Provider."
2. This Contract and Agreement shall be effective from Oc,T I d0113nd continue in force until
June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. 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.
The Provider 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.
1
L/2-,3/ 72
UWS-7A(KIU-IU/99)
J
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
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.
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.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
2
... CWS-7A (ICI0-10/99)
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.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld unty CI r o tM1 R WELD COUNTY BOARD OF SOCIAL
\aliftWas L SERVICES, ON BEHALF OF THE WELD
�5 COUNTY DEPARTMENT OF HUMAN
SERVICES
� 361 '
By: i '991 ` � 4 By:
Deput Clerk to the FAIN Chair Signature
Approval as to Substance: PROVIDER NOV 0 5 2012
WELD COUNTY DEPARTMENT Brad & Molly Land
OF HUMAN SERVICES 1831 25th Ave
Greeley, CO 80634
By: BY
tip)7, /D .p-/2
irectors ignature to Prov, r ignature/Da
/
' / By:
Provider's Signature/Date
3
„2.72
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the"Agreement") between
Brad & Molly Land
and the
Weld County Department of Human Services
for the period from a+ 0, ,,;(-0,v,.through June 30, 2013.
The following provisions, made this // day of U°11 , 2012, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider 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 Provider 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 Provider 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#1543324. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 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 Provider.
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.
, j/.a)- / �f
Weld County Addendum to the CWS-7A
•
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Provider will arrange reimbursement through Medicaid.
Any other special requests for transportation reimbursement shall require prior
approval by the Service Utilization Unit 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 Provider 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 Provider 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 Provider 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 Provider
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 Provider 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 Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider 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 Provider, 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'
2 Weld County Addendum to the CWS-7A
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public(federal, state, or local) transaction or contract under a public transaction;
3 Weld County Addendum to the CWS-7A
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A S-7A
(Exhibit B)
WELD COUNTY DHS
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 provider 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 91)One round trip a week ❑1'/)2 round trips a week
❑2)3-4 round trips a week. ❑2'/:) 5 round trips a week ❑3)6 round trips a week
❑3%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
9 Basic Maint.)No participation required ❑1)Once a month ❑1'/i)Two times month
❑2)Three times a month ❑2%)Once a week ❑3)Two times a week
031/2)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular c
special education plan?
❑ Basic Maint.)No educational requirements 91) Less than a ''/9 hour per day ❑1%) '/ hour a day
❑2) 1 hour a day 02 %) 1'/z-2 hours per day 03)2'/:-3 hours per day
❑3'/a) More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week 01%) 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 ❑3''/)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond ate appropriate needs with feedi
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.)
❑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.
❑2)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.
❑3)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 provider.
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) 91)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the CWS
• (Exhibit B)
WELD COUNTY DHS
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)
Assessment Areas ME Moderate/, ., C$
. T inve nts:
NQui Mild Ltd= Moderate Blab am r
0 1 1 1/2 2 2 1/2 3 3 1/2
Aggression/Cruelty to
Animals Cl ❑ ❑ ❑ ❑ ❑ ❑
Verbal or Physical
Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑
Destructive of
Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑ 0 ❑ ❑
Enuresis/Encopresis
O ❑ ❑ ❑ 0 ❑ ❑
Runaway
❑ ❑ ❑ ❑ 0 ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑ 0 ❑ ❑
6 Weld County Addendum to the CW.
(Exhibit B)
WELD COUNTY DHS
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)
n
_Assessment Areas O Moderate/ High/
LfL 2[ ca
' None Mild Moderate. Moderate 'Htgj Mob Emus COMnients:
0 -` 1 1 1/2 2 2 1/2 3 3 1/2 — '
Inappropriate Sexual
Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior
❑ 0 ❑ ❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑ ❑ 0 ❑
Medical Needs
(If condition is rated"severe", 0 ❑ ❑ ❑ ❑ ❑ 0
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ ❑ ❑ ❑ 0
Eating Problems
❑ ❑ 0 ❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑ ❑ 0 ❑
Requires Night Care
❑ 0 ❑ 0 ❑ ❑ ❑
Education
❑ 0 ❑ ❑ 0 ❑ ❑
Involvement with Child's
Family ❑ ❑ 0 ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) n 0 ❑i ❑ 11/2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 31/4
7 Weld County Addendum to the CW
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
RECOMMENDED
LEVEL OF SERVICE PROVIDER RATE
P1-P5
Level Rate
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate Age 15-21...$19.27/day ($586/month)
+ Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CW
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
• SERVICES, ON BEHALF OF THE WELD
IJWAAANA- COUNTY DEPARTMENT OF HUMAN
4E6La SERVICES
4ktiP
By: By:
Deput ler c to the ai 'k Chair Signature c---
NOV 0 5 2012
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Brad & Molly Land
OF HUMAN SERVICES 1831 25th Ave
Greeley, CO 80634
By: /G //i2
County rector's Signature/ at rirov. e ' tgnature/Date
I
7 /o/n/,c
By: may^
Provider's Signature/Date
9 Weld County Addendum to the CWS-7A S-7A
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