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Home My WebLink About20122311.tiff MEMORANDUM 1861 DATE: August 29, 2012 �..� \ TO: Sean P. Conway, Chair, Board of County Corn 'ssioners lilt_uNTY — � n� O FROM: Judy A. Griego, Director, Hu ei:r e e J � 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 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 Carter, Jeremy and Susan Foster Home July 1, 2012 —June 30, 2013 Windsor, Colorado 2 Corliss, Wade and Loni Foster Home July 1, 2012 —June 30, 2013 Greeley, Colorado 3 Crowder, Jeffrey and Elaine Foster Home July 1, 2012—June 30, 2013 Windsor, Colorado 4 Drury, Dean and Karla Foster Home July 1, 2012—June 30, 2013 Greeley, Colorado 5 Erbacher, Dan and Hallie Foster Home July 1, 2012 —June 30, 2013 Greeley, Colorado 6 Fisher, Matthew and Claire Foster Home July I, 2012 —June 30, 2013 Greeley, Colorado 7 Foster, Denise Foster Home July 1, 2012—June 30, 2013 Firestone, Colorado 8 Fritz, Nancy Foster Home July 1, 2012 —June 30, 2013 Evans, Colorado 9 Froggatte, Samuel and Rachelle Foster Home July 1, 2012 —June 30, 2013 Greeley, Colorado 10 Gomez, Oswald and Christina Foster Home July 1, 2012—June 30, 2013 Fort Collins, Colorado 11 Gutierrez, Elisa and Hoffer, Christopher Foster Home July 1, 2012—June 30, 2013 Greeley, Colorado _ ea-nu/H z eti - I) 2012-2311 12 Heimer, Sara Foster Home July 1, 2012-June 30, 2013 Greeley, Colorado 13 Hoeft, Kimberly Foster Home July 1, 2012 -June 30, 2013 Greeley, Colorado 14 Maronek, Dennis and Patricia Foster Home July 1, 2012-June 30, 2013 Firestone, Colorado 15 Martinez, Andrew and Jeanna Foster Home July 1, 2012 -June 30, 2013 Evans, Colorado 16 Mauk, James and Harriett Foster Home July 1, 2012-June 30, 2013 Johnstown, Colorado 17 McGee, Donna Foster Home July 1, 2012-June 30, 2013 Greeley, Colorado 18 Mena, Davie and Marie Foster Home July 1, 2012 -June 30, 2013 Greeley, Colorado 19 Middleton, Brian and Deborah Foster Home July 1, 2012 -June 30, 2013 Greeley, Colorado 20 Miller, Pamela Foster Home July 1, 2012-June 30, 2013 Greeley, Colorado 21 Moore, Earl and Patricia Foster Home July 1, 2012 -June 30, 2013 Lochbuie, Colorado 22 Parker, Brian and Beryldell Foster Home July 1, 2012-June 30, 2013 Greeley, Colorado 23 Pike, Wesley and Patricha Foster Home July 1, 2012-June 30, 2013 Platteville, Colorado 24 Risner, Larry and Vivanco, Katherine Foster Home July 1, 2012-June 30, 2013 Johnstown, Colorado 25 Ritter, Thomas and Deborah Foster Home July 1, 2012 -June 30, 2013 Firestone, Colorado 26 Roderick, Douglas and Kelli Foster Home July 1, 2012-June 30, 2013 Greeley, Colorado 27 Sena, Leo and Carol Foster Home July 1, 2012 -June 30, 2013 Windsor, Colorado 28 Spahr, Mary Ellen Foster Home July 1, 2012 —June 30, 2013 Greeley, Colorado 29 Van Den Elzen, Dawn Foster Home July 1, 2012 —June 30, 2013 Greeley, Colorado 30 Vincent, Jessica and Ryan Foster Home July 1, 2012—June 30, 2013 Greeley, Colorado 31 Wade, Michael and Jodyne Foster Home July I, 2012—June 30, 2013 Windsor, Colorado 32 Walker, Kurt and Jennifer Foster Home July 1, 2012 —June 30, 2013 Windsor, Colorado 33 Wyatt, Justin and Tracy Foster Home July 1, 2012 —June 30, 2013 Eaton, Colorado If you have questions, please give me a call at extension 6510. GWS-/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, - Irj0 �� 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, Carter, Jeremy and Susan, Provider ID#1556173, 1204 Tanglewood,Windsor, CO 80550, 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 UN/S-/A(K1U-1U/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 LWS-/A(KrU-1U/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 Boar WELD COUNTY BOARD OF SOCIAL Si La RVICES, ON BEHALF OF THE WELD NTY DEPARTMENT OF HUMAN y , .VICES 64( ) Deputy rerk to the Board ��r1i r r ✓ Chair Signatu� „ , •�' Piot'em AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Carter, Jeremy and Susan OF HUMAN SERVICES 1204 Tanglewood Windsor, CO 80550 By: Bye Directpr' Signatu /Date rovider's Signature/Date By: AXV)/\ _JU Provider's Signature/Date 3 o4/6,7 c73// • WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Carter,Jeremy and Susan and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this day of J 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#1556173. 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. 1 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 ❑l)One round trip a week ❑1'/:)2 round trips a week ❑2)3-4 round trips a week. O2%) 5 round trips a week O3)6 round trips a week O3%)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 O2)Three times a month O2%)Once a week O3)Two times a week O3%)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? O Basic Maint.)No educational requirements ❑1)Less than a'/,hour per day ❑1''/) hour a day O2) 1 hour a day O2 '/z) 1'/:-2 hours per day O3)2'/z-3 hours per day ❑3%i 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 ❑1)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 O 3)Constant basis during awake hours O3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding. bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%:) 11 to 15 hours per week ❑3) 16 to 20 per week O3%)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. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. O3%)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) ❑l)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 OHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that al.1 to this child. i y'Y :'7 a'"t" £s. },. .tt 2. :.t s 13 1 a'' ait. �, y 6 fn "4.?' !jt "li F°a m. ..i h v s 4 �.y4±r�„�w Tx"5°.yze 3? �l;e' �: 'r 1^�'^iw�y 'y Tja� x§x » °.;� '^i �+, a �: w2' 5 x, x ;":;144'.,(0 Tk 1 s7 yd n x x x Ps,-.Cr x a,;r VpS { art 4+l p ..i: ein i �.� .r .z x .. 5�, k�&xd 'z"m c '� w lat . ..:tt...a�,+.m :t�s'`t�� .t`*. istiX .. a§F. n�".,o r Ate`ay.%iwx trl '�an.+:v.?.E�.,, Aggression/Cruelty to Animals ❑ 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 0 0 0 Stealing ❑ ❑ ❑ 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 ❑ 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7e • ' (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that ar sly to this child. rev a ' t t ,iy ,� y. . f h + a. i er°':°v" t+s °"a' ' �, Ca a 1.4'31., "F*w f ' u y4 �' mss 'i s. ��, r � i`t �`t'. P'-:4:1' s Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ 0 0 0 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ 0 0 ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ 0 ❑ Medical Needs (If condition is rated"severe", ❑ ❑ ❑ 0 ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ 0 0 Eating Problems ❑ ❑ ❑ 0 ❑ 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ ❑ 0 0 ❑ ❑ ❑ Education ❑ 0 0 0 ❑ 0 0 Involvement with Child's Family 0 ❑ 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/ ❑ 2 ❑ 2% ❑ 3 ❑ 31/4 7 Weld County Addendum to the CWS-7/f (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Age 0-10...$16.32/day ($496/month) County Basic A.e 11-14...$18.05/da $549/month Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) 7.411 $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) 3;;; $29.59 2 1/2 +$.66 Respite Care INfb Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 31/2 +$.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 gia $30.25 day/$920 month(Includes Respite) Rate 110 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 ttci.r u.�` WELD COUNTY BOARD OF SOCIAL s La SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN J� 1 1/42 ERVICES ab Deputy erk tb the Boa:� �,.� hair Signature protein AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Carter, Jeremy and Susan OF HUMAN SERVICES 1204 Tanglewood Windsor, CO 80550 By. By. ty 4Qe rsvt is Signature/Date By: Provider's Signature/Date o20/8- 9 Weld County Addendum to the CWS-7A CWS-/A(KI0-I0/99) t INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT r' 1. THIS CONTRACT AND AGREEMENT, made this date, / 2// 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, Corliss,Wade and Loni, Provider ID#1547483, 26649 CR 60 1/2, 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 LWS-/A (KIU-IUf99) 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-/A(KIV-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 S` WELD COUNTY BOARD OF SOCIAL fi 1$ a `SERVICES, ON BEHALF OF THE WELD (tra' %CEOUNTY DEPARTMENT OF HUMAN RVICES 1 �I /4k, B ' ' . Deputy erk to the Boar r f i! Chair Signature Protein AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Corliss, Wade and Loni OF HUMAN SERVICES 26649 CR 60 1/2 Greeley, CO 80631 By: - By: `"7✓/i (� 07/7// Direct 's Sign re/Date dn9.Ottn vider's Signature/Date By: 7//7//2- Providers Sgnature/Date 3 ( 26/.;- 3// ' WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Corliss, Wade and Loni 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 day of v q 1Aq , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the/Agreement remain unchanged. GENERAL PROVISIONS 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#1547483. 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. 024%2-073, 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? EBasic Maint.)Less than one round trip a week DI)One round trip a week ❑1'/)2 round trips a week ❑2)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week 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? I[ asic Maint.)No participation required 01)Once a month O1%)Two times month 02)Three times a month ❑2%:)Once a week 03)Two times a week ❑3%x)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? Ergasic Maint.)No educational requirements DI)Less than a ''/z hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) 1'/z-2 hours per day ❑3)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? 01'.]ri p`C., Unasic Maint.)No special involvement needed ❑1)Less than 5 hours per week It7:�5 to 7 hours per week •? ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑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 feeding, bathing,th 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%) 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) asic 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. 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? 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-7A (Exhibit B) ' WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that as ill to this child. *""iR. i"v ,'�'°#"� "ta•�,4+' ^n. mss ��-�k a -"�„ n+� C^r s. c: x iri •:letg"'1'7 ' S'` .. 1 'tq ,- ;' 2"y * �;a '§i >4 t i s ,d' °, d. `zy1+:7 Et :"try tit y`4 iii .',a' s c.n a t- 1. ," tt, E " 4` 5 i 4„ 'd d ?.Sva a.- i +4 - '"e y , xatiE� y x ' „. . , bC w .I .`,3 fin° ,-i'x q a r k;: +'k' a s .r. �,..,q,,,y;:. a' c § a4...,411.41.41.* v��4 .3!4.$tea: .. ... .r..J. .'s .4 .. x. �. ( "je Aggression/Cruelty to Animals Ifil ❑ ❑ ❑ ❑ ❑ 0 Verbal or Physical Threatening ❑ ❑ ❑ 0 0 ❑ Destructive of Property/Fire Setting Ei7g 0 0 ❑ 0 0 0 Stealing ,/ tQ 0 0 0 0 0 0 Self-injurious Behavior a' 0 0 0 0 0 0 Substance Abuse E' ❑ 0 0 ❑ 0 0 Presence of Psychiatric Symptoms/Conditions ri0 ❑ 0 ❑ 0 0 Enures is/Encopresis V 0 0 0 0 0 0 Runaway I/ ❑ ❑ ❑ 0 0 0 Sexual Offenses II{ ❑ ❑ 0 0 0 0 6 Weld County Addendum to the CWS-7A (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 al 91 to this child. Ittagrrilta't ', 'aa a d�kg . '44'- : t3"�r"7y'k #'e, h+ ' X .4. j� '' 5d4 :170,0 reefed' °k �.T f l.ko M g r, . # y -;? l , �`' r"i-,'" f' ' tm i,a t'.k p %. f6;; '""n l a"'";; a da ` v a+s�; xhh. S -:`=.cam s:-, + b > '�.:;;I:,' "s'thiNgl ; z" : �a';s, rt . ay NSM ;: \:.4"::::t,;/,..,„;::1,„„.,.q.,,,, : + save. �t x r d�n;�m s`.w""+�w ��`di'Yk 1 v � � '� � 71 IV x, 1 . . � a e 1_°y t�. ,asist..°tcas. �". d...ax..iRsa+.:!:`"+ _,,.r.+t4 .. . . ..:. .._:::::::c.-::::„..: ..... ,,.. ,: ' Inappropriate Sexual W ❑ ❑ ❑ 0 0 Behavior Disruptive Behavior O' 0 0 ❑ 0 ❑ 0 Delinquent Behavior V ❑ ❑ ❑ ❑ 0 0 Depressive-like Behavior V ❑ ❑ ❑ ❑ 0 ❑ Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation 2' 0 ❑ ❑ 0 ❑ ❑ Eating Problems g ❑ ❑ ❑ 0 ❑ ❑ Boundary Issues ril/ ❑ ❑ 0 ❑ ❑ ❑ Requires Night Care ❑ 2" W ❑ ❑ 0 ❑ Education ❑ ❑ ❑ 0 ❑ ❑ Involvement with Child's 21"/ 0 0 ❑ ❑ ❑ ❑Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 Eli le/z ❑ 2 ❑ 2'h ❑ 3 ❑ 3Y/ 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE r =4n- Fri qLS}y-°'i`Cr i3=` ' � S A.e 0-10...$16.32/da $496/month County Basic kJ, foe 11-14...$18.05/da $549/month Maintenance oft Rate A.e 15-21...$19.27/da $586/month roo +Res•ite Care$.66/da $20/month $19.73 1ti +$.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) $36.16 3 1/2 040 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) $39.45 4 +$.66 Respite Care TRCCF Drop Down Total Rate=($40.11 day/$1220 month) AssessmentiEmergency $30.25 day/$920 month(Includes Respite) RatefiN Oki Effective 7/1/2008 8 Weld County Addendum to the CWS-7A • 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 S Q°O\OUNTY DEPARTMENT OF HUMAN - ♦ ` VICES in O 1/42 By: Deputy perk to the Boars'\�U 1711 Wil5 Chair Signature Fs`...' gain AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Corliss, Wade and Loni OF HUMAN SERVICES 26649 CR 60 1/2 Greeley, CO 80631 / By: By: U" dt LA C_- 0002 7 L2 C ty Di(e tor's Si ture/D Provider's Signature/Date D By: ��2( l�l'lr, 7/01/2. Provider's Signature/Date 9 Weld County Addendum to the CWS-7A l.ANS-/A (K1U-1(1/99) • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT l9/t JR 26 • 1. THIS CONTRACT AND AGREEMENT, made thisdate, 71 121 I'Z by and betweerr4 3/the Board of Weld County Commissioners, sitting as the Boa d of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department"and, Crowder,Jeffrey and Elaine, Provider ID#1611538, 316 Amber Drive,Windsor, CO 80550, 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 aDWW -cQ3/' LWS-/A (KIU-10/99) 71. 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 LWS-/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 Cl- k to the BoarIS. /'��► ELD COUNTY BOARD OF SOCIAL /21 g' /? VICES, ON BEHALF OF THE WELD �✓ NTY DEPARTMENT OF HUMAN ICES 1861. / ��1 ��yyyyyy111l11 y By: %. _��/fI s,� ��1 /d2 Deputy clerk fo the Board ��i 1 1 ! �� Chair Signature AUG 2 9 2012 Protein Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Crowder, Jeffrey and Elaine OF HUMAN SERVICES 316 Amber Drive Windsor, CO 80550 7-22-12 By: By: /// Direct r Signatu Date r vider' Signature/Date By: UJi\ `' L/Z/L I 1 - 1/12-2/iz Provider's Signature/Date 3 aoia -Si% WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Crowder, Jeffrey and Elaine and the Weld County Department of Human Services for the period from July 1,2012 through June 30, 2013. The following provisions, made this Z Z day of )14 I�� , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 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#1611538. 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. aii2-Gig 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 211''/)2 round trips a week ❑2)3-4 round trips a week. ❑2'/z)5 round trips a week 03)6 round trips a week ❑3'/z)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? Sf Basic Maint.)No participation required 01)Once a month ❑1'/z)Two times month 02)Three times a month ❑2'/z)Once a week 03)Two times a week ❑3'/z)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 01)Less than a ''/z hour per day 01%)1/2 hour a day ❑2) 1 hour a day 02 %z) 1'/z-2 hours per day 03)2'/z-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 ❑l)Less than 5 hours per week ❑1'/)5 to 7 hours per week 2)8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week 01)3 to 4 hours per week 011/2)5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to I5 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. 011/2)Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. ❑3)Face-to-face contact weekly with child and occasional crisis intervention. ❑3%z) 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 CWS-7A (Exhibit B) WELD COUNTY DHS • NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. ", ,„�' r 4" r. s vt 4 „ti condition.!.. try .4"v yw_ a p,: # d e �r f� s� 1 wrg��"1' t rye `' .: + y w k. s �" ti a i "is 't 'a ksa r, y . rZ �.� �L ins 'i :, . ` ''''''%;-'71A- ' ;J .,ten - Yt: '` ,� '"t ,1 ,tRrt .,4 � u 't4`s " d,. +. ^Ed.r , i` 'iy*e 3 llit yr. 34,=.7-41:41:04451,44. Y• 5" a+' n iIE1i N I:1..4.1" ''e,`• ..5+1:4i.: o : yr: e.. f I 4�i ry t p x' x3 ` � d .v ,3 k:' '`. i x. '��iaasgi7.s.. .rdi v �•,•§rae %,, :$1.%,,•:-:,. ;till} L u. .. P.Nt'ktv�d.Ad.: «.�,',... ...dd P{ . . .3.:.. w Fu�. .. ..- , .,C _ ;t Y,Ito Aggression/Cruelty to Animals ❑ ❑ ❑ 0 0 0 0 Verbal or Physical Threatening ❑ ❑ ❑ ❑ O O O Destructive of Property/Fire Setting 0 0 0 O O O O Stealing ❑ 0 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 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway 0 0 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 ❑ 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) • • WELD COUNTY OHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. ,;" ��" 9`sF �*Ay` ��+,�y, ''ai Y c* v ks r1."' z '� r v .m $ :4 9. 9 y s ,7 h'3 4Q.V. � t2' F{ v¢a'a t tINA; i l' a1 k. {�.' v.° #.�i 3 a y to e t ; kx 4 y "s fit'' . : . . i +i "* :4.a £ r ;< . s "Ay:a :54ilk ;It::+ ' 5 , "' raw. G "x.§. 1 ..4;:-.„12, yrE ti.:3;.72.S3:; S' i aC i'.: W} .n Yt�1ziii` {^h�i �m�. 4 �. � .:� w �+.. . +'t 4�..rn x,.....�. � ...s:w[� <. a..=-".:4- 4k..xai ..ate. .. .. �� k� r, Inappropriate Sexual Behavior ❑ 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 O O Delinquent Behavior ❑ O 0 0 0 0 0 Depressive-like Behavior ❑ O 0 0 0 0 0 Medical Needs (If condition is rated"severe", 0 0 O ❑ ❑ 0 ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 ❑ O Eating Problems ❑ 0 O O O O O Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ ❑ ❑ ❑ ❑ 0 0 Involvement with Child's Family ❑ ❑ 0 0 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) El 0 [ID ❑ 1'h ❑ 2 ❑ 2''/ ❑ 3 ❑ 3''/ 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE • '. i t Age 0-10...$16.32/day ($496/month) County Basic A.e 11-14...$18.05/de $549/month Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care TN Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care 11/49 414 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) $36.16 31/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 A430 $39.45 TRCCF Drop Down +$.66 Respite Care tai 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-7A 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 Bo. , WELD COUNTY BOARD OF SOCIAL ,I E Ill ♦ SERVICES, ON BEHALF OF THE WELD � OUNTY DEPARTMENT OF HUMAN RVICES . 1861 •' / i '`', .. BY I�:/// /1 ��. , s�. ��`��' ..�' : 27 Deputy ' erk o the Boar Chair Signature Protean AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Crowder, Jeffrey and Elaine OF HUMAN SERVICES 316 Amber Drive Windsor, CO 80550 By. By: 7-22 - /Z C my Dirk or's Si ature/D ovider's Signature/Date By: 7 2z rovider's Signature/Date o?oic2-RS// 9 Weld County Addendum to the CWS-7A 4.W ,-/A(K1U-IU/99) INDIVIDUAL PROVIDER CONTRACT • FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT Q / 1. THIS CONTRACT AND AGREEMENT, made this date, S1/4 /1-• 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, Drury, Dean and Karla, Provider ID#1606578, 1301 38th Ave, Greeley, CO 80634, 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 (9 002- 6?3i/ F_.WS-/A (Ki II-IU/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 k;WJ-/A(KLU-IU/9#) 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 Bo— s La% ELD COUNTY BOARD OF SOCIAL C" 'VICES, ON BEHALF OF THE WELD t {L NTY DEPARTMENT OF HUMAN y ` + E'3 ICES to , +/t By: .,y, , � h Deputy erk t• the Board �' y� Chair ignature AUG 29 2012 Piotem Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Drury, Dean and Karla OF HUMAN SERVICES 1301 38th Ave Greeley, CO 80634 By: 3/6 I Z 44' aCç Date Provider's Si nature/D e / By: _)oa,v- 27/l'/ /,Z Provider's Signature/ ate 3 d®/2- aS// WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between 4.. Drury, Dean and Karla of&C and the 4 Weld County Department of Human Services for the period from - July 1, 2012 through June 30, 2013. �? * The following provisions, made this (Q day of AAA , , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of t _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#1606578. 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. 1 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 ❑l)One round trip a week n1,)2 round trips a week ❑2)3-4 round trips a week. ❑2%z)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 ❑2)Three times a month 02%)Once a week 3 Two o times month 03) times a week 03%)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 ❑l) Less than a''/z hour per day 01/2) 1/2 hour a day 02) 1 hour a day 02 %3) 1'/z-2 hours per day 03)2''/-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? 0 Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1'/z)5 to 7 hours per week F.)8 to 10 hours per week 02%) I I to 14 hours per week 3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond ace appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week OI PA)5 to 7 hours per week 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%)Face-to-face contact one time per month with child and occasional crisis intervention. 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) S1)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-7A (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT :ggPlease rate the behavior/intensit of conditions which create the need for services that as ply to this child 3h -ak54.4h"3e r` 5.+ t 3 x m• 3+ ktv ks'k*s2 kr w ;:'�:,s� hx� "a �flf"� 4 t ii/-'..7,' t r that n J ".' k kv "'-'k i u�e'E { ,-"I"iXce...k'a pd E.t'y NAP: 1i ! Ski . ( IO j4 SA{1 •S yk 9 a '- '. :9 # r. r T4. vp"b 54" t$y is it '4'e . r , r'. d'' s i. *Pkti k't "rz- ) '' a yam' 's ,,,, 3 '" */",;,..f-. t ak r I. "ir; a�* - ;x` :b a a 41 k 'c az ? L :-Tv--..k.,'. -,. ;y-4„:„I1/44.f„,i': -,,...1:,„}A i b ti ; ih : y 5-.1. v :1 i ire a• 7th. z . � 4 {�i� 3� �` "''�:s r „5't: ty ,ry'�' r «� a,n x � r � -£F'v d %}:' t F4%:. �,c £ 4 E k k y{-',,iN: F }s„,'74'„it Aggression/Cruelty to Animals Yom`�( ❑ 0 0 0 0 0 Verbal or Physical Threatening 0 0 ❑ 0 0 0 Destructive of Property/Fire Setting 0 `2f 0 0 0 0 0 Stealing ❑ ❑ % ❑ 0 0 0 Self-injurious Behavior ❑ Vi.. O 0 0 0 0 Substance Abuse IOL O 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 ❑ 0 0 0 Enuresis/Encopresis ❑ 0 X 0 0 0 0 Runaway ❑ 0 0 0 0 0 Sexual Offenses 6 Weld County Addendum to the CWS-7A • (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 a..1 to this child. .ar v vz r` #`L a: p44.y a �� TMt��t644, % '%§i t a��c.af �r>'�rm"s� "� t r {� , ,�IC : : 45,44 cts .. 7 a s a ,: �''v i}v#^ai.{r a S a' 't t a �,1. a x • a 1 n i u t �°s§ a a u a ,� e `�#' t $.+i4. is ,y P110 '4 u i i 1, V r i: IT.e'1: +44 a4psa c'' s y §`" 1 ". f," kir t 4..#'" �" 'a to ° F ,� ' tt 't, . . 'r '. ° ,. aµ s r rt'l #y a a s U f.4. .. - � w{ak s#.�4i..eu^s:+ :f'�. x+°a�!^:, v'°:eq..^.�' a .wi<v Inappropriate Sexual Behavior 0 % 0 0 0 0 0 Disruptive Behavior O ❑ ❑ o ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior O 0 ' ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", please complete the Medically ❑ O O O 0 ❑ fragile NBC) Emancipation g O 0 0 0 0 0 Eating Problems ❑ ❑ \y1 ❑ ❑ ❑ ❑ Boundary Issues O 0 0 0 0 0 Requires Night Care O OX 0 0 0 0 Education O 0 0 0 0 0 Involvement with Child's Family ❑ 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2Yz ❑ 3 ❑ 3'h 7 Weld County Addendum to the CWS-7A 1 ' (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE t� { x rei 4. i ,: NN A.e 0-10...$16.32/da $496/month ffni County Basic leA.e 11-14...$18.05/da $549/month Maintenance 7,4 RatePO A's 15-21...$19.27/da ($586/month +Respite Care$.66/da ($20/month $19.73 1 41.66 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) Fat $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care ts Total Rate=($33.54day/$1020 month) 0110 $36.16 3 1/2 t4 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 P . $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) na Assessment/Emergency tis4 Rate $30.25 day/$920 month(Includes Respite) tigEffective 7/1/2008 8 Weld County Addendum to the CWS-7A ' 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 I .. . WELD COUNTY BOARD OF SOCIAL k � SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN • , � ERVICES 1861 �,Q. _.' -.N Deputy 'erk to the Bo. 'tb a Signat Protein AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Drury, Dean and Karla OF HUMAN SERVICES 1301 38th Ave Greeley, CO 80634 By: By. S 84 , Co n Directo's Signa re/Date Provider's Signature/D t By: FAS/ rovider's Signatur /Date 9 Weld County Addendum to the CWS-7A LWS-/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, 2//S// 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, Erbacher, Dan and Hallie, Provider ID#1546381, 3850 Cheyenne Dr, Greeley, CO 80634, 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 ao/a - a,3// LWS-/A(KIU-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 LW ,-/A(K1 U-f U/99) •, r d 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 Bo- ,f:� La ELD COUNTY BOARD OF SOCIAL `� RVICES, ON BEHALF OF THE WELD UNTY DEPARTMENT OF HUMAN s VICES tam/ tam By: ~ (Ala Deputy erk to the Board i` ' \ Chair Signature AUG 2 9 2012 Protein Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Erbacher, Dan and Hallie OF HUMAN SERVICES 3850 Cheyenne Dr Greeley, CO 8006344 By: - By: /94,,,, (.. `— 0 p %c�//) Direct is Sign re/Dat Provider's Signature/Date By: 7� CF�j�/ai�ifJCJ 845-//c2— 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 Erbacher, Dan and Hallie and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this /, `day of/97.tsu.Sf , 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#1546381. 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, 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'/x)5 round trips a week 03)6 round trips a week 03%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? 0 Basic Maint.)No participation required ❑l)Once a month 01%)Two times month 02)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 01)Less than a''/z hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 %) I'%-2 hours per day 03)2%-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week 01%)5 to 7 hours per week 02) 8 to 10 hours per week ❑2'/2) 11 to 14 hours per week 0 3)Constant basis during awake hours ❑3%1)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week 01)3 to 4 hours per week 011/2)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑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. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. ❑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? 00)Not needed or provided by another source(i.e. Medicaid) ❑I)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-7A (Exhibit B) WELD COUNTY DHS ' NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child. Y � 't. • i�FsSa4� 'k:,p "a,a "y,' *. t +w {t fruit' e t'a'i , > yy} + ek ,ci"r°Se-s-, e ,,� ''-`�"'Lliottly v:.crw4 :-.....:7„7::`"4 '�wi,'acY s � 1 a, i:1:19 . .a i,,q l' „ " Pa,R ±'z, sal tx • t n•i ` ''••• ''. . .tr Y tigSy P ,� y Y $• � � �"x`Y �. :'� �' 1`N^ � ,T a I} R"'ag � 'k 5 y <k41.y�'• �'�{ ,.may + ;v:: ; .... . . '.x .. ..t v.. i, �. ... ... i$ur t'�.a� k :�c�.4�..LwKY°f4(g�.4d .. �i �} Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ 0 ❑ ❑ ❑ 0 ❑ Destructive of Property/Fire Setting El 0 El El 0 0 ❑ Stealing 0 ❑ 0 ❑ El 0 0 Self-injurious Behavior 0 El ❑ 0 El 0 0 Substance Abuse El ❑ 0 0 0 El 0 Presence of Psychiatric Symptoms/Conditions El El 0 ❑ ❑ 0 0 Enuresis/Encopresis El El El ❑ ❑ El 0 Runaway El El El ❑ El El El Sexual Offenses ❑ El ❑ El El ❑ El 6 Weld County Addendum to the CWS-7A (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 a'.I to this child. ,:;. P:' u .t :4? : :. n 1 s t rs * s' "..11A ., mas. k. $ 4 �, ' , y�ttdd �4- aAkill?' r�IVI i • g. i5 rt .. f '�'3s� p3 °':tt`°f .d x ''tra. , .a idea 3..:c% rni„��ab u' 3.k; .I :Le, .�„u.'t5._. .,::. . .. .... ° .s §v Inappropriate Sexual Behavior ❑ 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 ❑ 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ 0 0 ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation O 0 0 0 0 0 0 • Eating Problems ❑ 0 ❑ 0 0 0 0 Boundary Issues O ❑ 0 0 0 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 ❑ 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 2'h ❑ 3 ❑ 3'/2 7 Weld County Addendum to the CWS-7A . ' (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ettaitekitiniatliEtinfatittaillieNtriiiiitg OfW.T at* itike iffbraci Age 0-10...$16.32/day ($496/month) County Basic grX Aqe 11-14...$18.05/day ($549/month) Maintenance Rate tpgi 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) Sir $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) 4,6 $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) teet $29.59 21/2 4.66 Respite Care tig Total Rate=($30.25 day/$920 month) Lig $32.88 3 4.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 112 4.66 Respite Care itti Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down Pflasir. +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Or $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7A L '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 t, WELD COUNTY BOARD OF SOCIAL 4 } . I-a' SERVICES, ON BEHALF OF THE WELD OUNTY DEPARTMENT OF HUMAN 1b61tes� �� RVICES By: / Dputy 'erk to e Board'tZ %flj/By: Chair Signature Protein AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Erbacher, Dan and Bailie OF HUMAN SERVICES 3850 Cheyenne Dr Greeley, CO 80634 By: By: 4., -t 2/15/12 Coun irect ' Signat e/Date Provider's Signature/Date BY: -7%61,0 4, 8/l 5//'d—j Provider's Signature/Date aei�-O7,V/ 9 Weld County Addendum to the CWS-7A L W S-/A(K IU-I U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, t'-13 -/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, Fisher, Matthew and Claire, Provider ID#1532312, 5022 W 2nd St Rd, Greeley, CO 80634, 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 a,0i c,3// LWS-/A(KIU-IU/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 CWJ-/H(KFU-lU/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 SERVICES, ON BEHALF OF THE WELD S 1.da OUNTYDEPARTMENT OF HUMAN VICES K,q4y1/42 ' � Deputy ��erk to the Board $ air Signature � °p� I Protein AUG 2 9 2012 Approval as to Substance: ♦r • �I PROVIDER WELD COUNTY DEPARTMENT Fisher, Matthew and Claire OF HUMAN SERVICES 5022 W 2nd St Rd , Greeley, CO 80634 By: 1�JVV`C&LV �A (� By: �-✓v cam— 1S —12 Dire or's Sig ture/D Provider's Signature/Date JJ By: �✓r� �— fi3 lZ Provider's Signature/Date 3 0170/21- cS// WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Fisher, Matthew and Claire and the Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made this day of , 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#1532312. 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. 07O/a- ct9S// 1 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 - • 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 s j(,a COUNTY DEPARTMENT OF HUMAN SERVICES By i1/ // i �� i��I r�� :y: Deputy/ erk to the Bic« (its Chair Signature Protein AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Fisher, Matthew and Claire OF HUMAN SERVICES 5022 W 2nd St Rd Greeley, CO 80634 By: By: t5"-- 13—I Z u ty ire tor's S ature ate Provider's Signature/Date '13 2 Provider's Signature/Date 0/07 o73// 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-IU/Y`J) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, luquAc '1..11001 A 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, Foster, Denise, Provider ID#1551571, 10656 Bald Eagle Circle, Firestone, CO 80504, 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. RCC,D AUG. Not to make any independent agreement with parents or guardians. Cl H 17 6 2©1? 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. 1 070/69—c S// /A (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 (.WS-/A(K10-10/99) 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 lerk to the B WELD COUNTY BOARD OF SOCIAL /Q p s gsa SERVICES, ON BEHALF OF THE WELD • , OUNTY DEPARTMENT OF HUMAN '�ow-�ERVICES .ov 441 By: Y i�� Ste( 7-7-2 -' Deput lerk to the Boar 7` iG i '\ Chair Signature AUG 2 g 2012 �+.. ...r+� rioter, Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Foster, Denise OF HUMAN SERVICES 10656 Bald Eagle Circle Firestone, CO 80504 •By: ci ( Q� By: ��r ' of f3/ Direct is ig ature/D to Provider's Signature/Date By: Provider's Signature/Date 3 aO/G-07,9 if WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Foster, Denise and the Weld County Department of Human Services for the period from July 1,2012 through June 30, 2013. The following provisions, made this 13 day of A u Sf, 2012, are added to the referenced Agreement. Except as modified hereby, all terms of t 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#1551571. 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. 02 0/a -078/2 1 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: I. 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 DI)One round trip a week ❑1'/z)2 round trips a week ❑2)3-4 round trips a week. ❑2%z)5 round trips a week 03)6 round trips a week ❑3%z)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 01)Once a month 01%)Two times month 02)Three times a month 02%)Once a week 03)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 or special education plan? 0 Basic Maint.)No educational requirements O1) Less than a'/z hour per day ❑1/)'/z hour a day ❑2) 1 hour a day 02 '/z) 1'/z-2 hours per day 03)2'/2-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 011/2)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond a2e appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%) 5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3''/)21 or more hours per week Comments: A I. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/z) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 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) ❑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-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create they need for services se that a..ly to this child .„ 4 {xy x,c—„`e°e^5`�s F'kSi LE ~ a r1 .. 1 `ham W }k'Gv''a "'' this y *� L�xry LS fM. Ni' b j t OE 'q.5 3 r{"d b�nvy�� t R �' 4 ti s, P i r`tjt, a &l { g: x'5 5 o- d i *Id..�C t ,¢. 14.r.:7-'1.,0 1,41 9 s ht~'LM�i i f •,6sc ; Li* ",5 y' r t v a rj:,, ,y,,ir d i ,_ k s-`s,"+tfi a z ,�v-:'-' lit^ 4: i C!k' re`s y'�*�og`� s - x� }�� i lit a �' a . i uf `* �, �,ii � Aggression/Cruelty to Animals ❑ ❑ 0 0 ❑ ❑ ❑ Verbal or Physical Threatening 0 ❑ 0 ❑ 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 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 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 ❑ Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child ₹ a. *u' - erg 2*' v,'z' 5 e' „,kf', r ' + i it f� i b ihT ri i s)•. is R z g /,'' . .s � `ra!;^.. ,# Yfi s."° ,.:N.;"�� ul x a g a+. w i i K h + l'/N „ , � .1;1'114ii:::-5-;?''''''-' * u $Y' k..v'�..,. A T' y '''1-;'19,. i ,.,€..ad r vA-. .ist ::,:4 :t a "t"yy''«x 1- € • „n 1 4 4 "� h � t& A � m tick ".Y d ffi ig 't""4 q r.,;' 'f ril314 d Y Y i 1a* Inappropriate Sexual Behavior El 0 0 0 0 0 0 Disruptive Behavior ❑ 0 ❑ ❑ ❑ 0 0 Delinquent Behavior ❑ ❑ 0 0 0 0 ❑ Depressive-like Behavior ❑ ❑ El ❑ ❑ 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 ❑ El ❑ ❑ El Eating Problems ❑ ❑ 0 ❑ ❑ El ❑ Boundary Issues ❑ El ❑ 0 0 ❑ 0 Requires Night Care ❑ El ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ El El ❑ Involvement with Child's Family ❑ ❑ ❑ El 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 Lill ❑ 1'/z ❑ 2 ❑ 2'% ❑ 3 ❑ 3'% 7 Weld County Addendum to the CWS-7A • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE yx lI a� ?c - Me 0-10...$16.32/day ($496/month) County Basicorm Age 11-14...$18.05/day ($549/month) Maintenance Rate A.e 15-21...$19.27/da $586/month +Respite Care$.66/day ($20/month) $19.73 +$.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) $26.30 2114 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2krA +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 40 3 +$.66 Respite Care 04, Total Rate=($33.54day/$1020 month) 004 400 $36.16 3 1/2 +$.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 reFI Rate $30.25 day/$920 month(Includes Respite) Effective 7/1/2008 8 Weld County Addendum to the CWS-7A • '+ 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 y SOCIAL 7's SERVICES, ONT BEHALF OF THE WELD • / s Q"®`�COUNTY DEPARTMENT OF HUMAN y SERVICES / Ito t-. 1/42 By: I�I//// / �� %..(Lralidk .:y: —> Deputyylerk-to the Boa'\ n 11 Chair Signatu Proem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Foster, Denise OF HUMAN SERVICES 10656 Bald Eagle Circle Firestone, CO 80504 /` • By: By: Cou t Directgr' Signa /Date Provider's Signature/Date By: Provider's Signature/Date 9 Weld County Addendum to the CWS-7A LWS-/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, 3u kK Z0r ZaIZ 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, Fritz, Nancy, Provider ID#1539167, 3925 Stampede Dr., Evans, CO 80620, 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 ad/a-aS// L WS-/A(KIU-IU/99) 1 T. 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 l:WS-/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 B•., Tr, S WELD COUNTY BOARD OF SOCIAL na.O SERVICES, ON BEHALF OF THE WELD fi OUNTY DEPARTMENT OF HUMAN ERVICES dn 412 pBy- er' i�' Deput lerk to the Boar. yJl TT it y Chair Signature AUG 2 9 2012 Protem Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Fritz, Nancy OF HUMAN SERVICES 3925 Stampede Dr. Evans, CO 80620 By:(1,i .� .cud) By: Direr or's i atureffiate ovi er' ture/Date By: Pr vider' Signature/Date 3 • WELD COUNTY ADDENDUM l B4,,V` pi. To that certain Individual Provider Contract for Purpose of Foster Care i6 Services and Foster Care Facility Agreement (the"Agreement") between 4 9. Fritz, Nancy „>7, and the Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made this Zc,2 day of u , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the greement 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#1539167. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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. aia- as// Weld County Addendum to the CW S-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'/s)2 round trips a week ®2)3-4 round trips a week. ❑2'h)5 round trips a week O3)6 round trips a week ❑3%)7 round trips or more Comments: $E 15 u1/4.t& Fu-n Thae_40i-k. tvo.yt.1 SrLMt._ 4-03at 3 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 01)Once a month gi1''/)Two times month O2)Three times a month ❑2Yx)Once a week O3)Two times a week O3%)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 01)Less than a ''/x hour per day ❑1'/) 1/2 hour a day O2) 1 hour a day O2 1/2) 1'/:-2 hours per day O3)2%r3 hours per day O3%)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 O1)Less than 5 hours per week 01%)5 to 7 hours per week O2) 8 to 10 hours per week ❑2%:) 11 to 14 hours per week O 3)Constant basis during awake hours O3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical, and/or occupational therapy? Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week O2) 8 to 10 hours per week ❑2'/:) I 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.) ❑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. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. O3%)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) 211) 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-7A (Exhibit B) WELD COUNTY OHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a 8 81 to this child. W.,,,2,2:744,2:;',',,;aw: 't 'rc - i x4k x rani.�4 �;,uud„^ t. n .§�215 : xn a t1$. _�,aa F. t � � � p C, .. 1 a #x ' 4.-0--,0444 .5:::-.', r :s�a. ..;F:.-„:4 ..,„� v �$ § x 5deitari ". # i. t?m%c°f,tav - s ik.:...xt .m',.,t,`1. .M�'t .,x'w t..F wGa"• Aggression/Cruelty to KtcKed nA^cox op Animals ❑ ® ❑ ❑ ❑ ❑ ❑ cr'^ - O Cflb'c,rs Verbal or Physical Threatening ® ❑ ❑ ❑ ❑ O O Destructive of W try Ant 5lnttotA' Property/Fire Setting O 0 O O ❑ O O Pteran" ‘ t'`'om` 1 Stealing © O O ❑ ❑ O O Self-injurious Behavior N ITS W pt L Lair". Substance Abuse Ir O O O O O O Presence of Psychiatric Symptoms/Conditions O O ❑ ❑ ❑ O O Enuresis/Encopresis O ❑ O O O O O Runaway r, �/ H AS S"W..�* tokr IZ li. O O ❑ O O nntttOt A.t..)fuS Sexual Offenses ❑ O O O O O 6 Weld County Addendum to the CWS-7/ (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that ap.l to this child. y ''9 ,' �., 'P *.r' i at a i 'i i tW rt i y e w r y{ a r f s a ax s.a.' R S• �I ':,� '5w f f 3. z r 74 x'.. aK "'sp3a"2 a'x>!ii 4: h. a t`` '.? ,' t t,`r w �'.. 'T1t. a�-y371' }��i `h l al sn,.'k:Y�i'gyrgs�Jeil R„ $ ±.','Trieft 4�1 . ' bF° 'aF ': , :�a' �a p t^$ i+ s. M 4t t' P K a F Ct`' 'S a!' wm ``r ° Y R {I" 'k .' k .. F P I� A da "� >g t X SI �> as"rs as a . ,s4- ' Ai 's Id s sM ' .; y ..: °�'sy. i S.v-Pa' y 3•1a s4}# Y• } r 1 5 - ya * ittOliatirai k :,..::;...„,....k. ,...!:;..! v. Inappropriate Sexual Behavior ® 0 0 0 0 ❑ 0 Disruptive Behavior 0 0 0 0 0 0 0 Delinquent Behavior © 0 0 0 0 0 0 Depressive-like Behavior P uxv Wcc�R.ct.' 0 U 1 0 0 0 0 0 r,bs�u 'S Its (ar 1. L4 Iti.64.40-0-4-3 Medical Needs (If condition is rated"severe", 1:T ❑ 0 ❑ 0 ❑ ❑ please complete the Medically S� fragile NBC) Emancipation 0 0 0 0 0 0 Eating Problems © 0 0 0 0 0 0 Boundary Issues IEI 0 0 0 0 0 0 Requires Night Care Er 0 0 0 0 0 0 Education g 0 0 0 0 0 ❑ t.U5rrS WaCk FAT-. Involvement with Child's �1 Monaa_ w Tte.e � Family 0 0 Q RI 0 0 0 t...5atm- CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ®1 ❑ 11z ❑ 2 ❑ 2'/ ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS-7F t (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE • rit Age 0-10...$16.32/day ($496/month) County Basic '5, Age 11-14...$18.05/day ($549/month) Maintenance kit Rate era` Age 15-21...$19.27/day ($586/month) .ff +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) 344 $23.01 1 1/2 # +$.66 Respite Care Total Rate=($23.67 day/$720 month) cZ $ $26.30 2 +$_68 Respite Care Total Rate=($26.96 day/$820 month) Ark' $29.59 21/2 +$.66 Respite Care =(Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care a�" Total Rate=($33.54day/$1020 month) tg 5.41 'y5{ $36.16 3 1/2 +$.66 Respite Care 'rv4 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 g x $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7A 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 °Q°a` COUNTY DEPARTMENT OF HUMAN t =c� RVICES 1861 � ke By: J / i Deputy t erk to the Boa Chair Signature Protein AUG Z 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Fritz, Nancy OF HUMAN SERVICES 3925 Stampede Dr. Evans, CO 80620 By: By: �y 744 2 C u ty Direc ors 'ign ure/D e Provider" Sign /Date By: G-�2 r zo/z_ ider's Signatur ate 026/07-ow 9 Weld County Addendum to the CWS-7A U W J-/A tKIU-fU/YY) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 1 J21 J I Z by and between the Board of Weld County Commissioners, sitting as the Bo d of ocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department"and, Froggatte, Samuel and Rachelle, Provider ID#1601426, 213 N 52nd Ave, Greeley, CO 50634, 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 a(/c2 &3// LWS-/A(K I.U-W/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 LWS-/A(KIU-lU/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 SERVICES, ON BEHALF OF THE WELD E lLa1 COUNTY DEPARTMENT OF HUMAN ERVICES By: / 7// f►i�i�/,�%r.� �.:u� �: (� Deput clerk to the Bo y Chair Signature AUG 2 9 2012 ?totem Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Froggatte, Samuel and Rachelle OF HUMAN SERVICES 213 N 52nd Ave Greeley, CO 50634 By: By: Direct r' ignat /Date •rovider'. :g ! -/Date By: . 1' // •u Provider's 'i. atu = tae 3 ao/a-alS// WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of FoVg-71 are Services and Foster Care Facility Agreement (the "Agreement") between Froggatte, Samuel and Rachelle and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013.The following provisions, made this 71 day of 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the reement 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#1601426. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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. c9eW- 4,71 1 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 01)One round trip a week ❑1''/)2 round trips a week ❑2)3-4 round trips a week. ❑2'/z)5 round trips a week 03)6 round trips a week ❑3'/z)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required DI)Once a month ❑1%)Two times month ❑2)Three times a month ❑2%z)Once a week 03)Two times a week ❑3'/z)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 ''/z hour per day ❑1'/z) '/z hour a day ❑2) I hour a day 02 %z) 11/2-2 hours per day ❑3)2'A-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 ❑1)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 0 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 feeding, bathing,grooming, physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/z)5 to 7 hours per week ❑2)8 to 10 hours per week 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.) ❑l) 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. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same 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) DI)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-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. AreyfFCc.yam a * tg. ei 3s �u .,� aa.s 5,- -cox . .a ns .a=, 'I.; ',7c: r i..17....7.7„4:1:: + r` ; 3`v i�.. u"" r-i Scm;p �,v,ac it .r'k'�" r�r 7 ,,'a ...t "a. i g. M E a r x t iftig `a ' # 4 ,x Ca r '.a.y e 4 r AIc xHi : _ x x at*le } Y t 1.'o- 'av �� " .', .r -,y,s Pa yyS*' " �h"*':`C . c ' � �, T A:' a p'o-'° ° ,�. s...A 3 i �. .r x�t } a a `. bra„ 6 � '` 5 yt Lty 4 4 1 4 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior CI ❑ ❑ ❑ 0 0 0 Substance Abuse El CI CI 0 0 0 0 CI ❑ ❑ 0 0 0 0 Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis ❑ 0 0 ❑ 0 0 CIRunaway CI ❑ ❑ ❑ CI 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7/ • (Exhibit B) - WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. t a x%u kt t!@ �' >flit�� ,�°�' ? ; sz av a 1,‘;..:w a x , i 5 fa, TZ,I,k'aF..' hpr "L. S ?'@'¢P '/. ,.4 4 d¢ F� ,¢ ,. "ws .:� 1 • 4 , `^° +t':Y.'n" b ¢.5uu�ty�" �e �,�'S,y�' �a4ax. aA +tai r ! ?y,L, '`�r i ke�'`a' T ;'w a' T. 7•Sta rr \'12S,e p s • z. 'It ,. ' '� r� 1^'� 44 �� 'd�*�as'fr .� °��A �...,.„._.¢.. ._..... x� x,. twc��.. Inappropriate Sexual Behavior ❑ 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 ❑ ❑ 0 0 Delinquent Behavior ❑ 0 0 0 ❑ ❑ 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 ❑ ❑ 0 0 Eating Problems O ❑ ❑ ❑ ❑ ❑ 0 Boundary Issues El ❑ ❑ ❑ ❑ 0 ❑ Requires Night Care ❑ 0 ❑ ❑ 0 ❑ 0 Education ❑ ❑ ❑ ❑ 0 El ❑ Involvement with Child's Family 0 ❑ ❑ ❑ ❑ 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑i ❑ 1'h ❑ 2 ❑ 2'/ ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS-7/6 (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE . ;' . .'�. 4s (b .: W Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance 1$:git 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) 411. $29.59 2 1/2 +$.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 rge Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Ltiffi Assessment/Emergency • $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7A ♦ ♦ 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 i llso COUNTY DEPARTMENT OF HUMAN SERVICES / x ` 1/42S� Ito f By: ti _� ��11i'. /!��♦ By: 742 027 Th_) Deput clerk to the >+ / \ Chair Si nature �`'� .►'� protein AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Froggatte, Samuel and Rachelle OF HUMAN SERVICES 213 N 52nd Ave Greeley, CO 50634 By. By' 51114 ""' o m ire y tor's Sig ture/D e Provider'signatu e By. Provider's Si ture/ a69/a-a3y, 9 Weld County Addendum to the CWS-7A LWJ-/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, .274) SC/ , 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, Gomez, Oswald and Christina, Provider ID#1588508, 7226 Matheson Dr., Fort Collins, CO 80525, 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. r.. 4. To cooperate fully with the County Department or its representatives, and participate irctrie development of the Family Service Plans for children in placement, including visits wit :4)4. 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. w 7. Not to accept money from parents or guardians. ry 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 DV/al- agi/ LWS-/A (IC IU-IU/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 L W S-/A(K I U-10/99) • '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 Bo- ./i . WELD COUNTY BOARD OF SOCIAL IS /..t% SERVICES, ON BEHALF OF THE WELD S ` <'' \ OUNTY DEPARTMENT OF HUMAN a . ERVICES 61 �`t By: Deput / lerk to the Boa P i . \ Chair Signaa urge AUG 2 9 2012 +• ,.� Protem Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Gomez, Oswald and Christina OF HUMAN SERVICES 7226 Matheson Dr. Fort Collins, CO 80525 By: By: 1'/2 DirePt s Sig re/Dat Pr ider's Signature/Da By: / a-- rovid 's Sig ature/ to 3 ��a-aS// WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care ,,, Services and Foster Care Facility Agreement (the "Agreement") between Gomez, Oswald and Christina c and the `- Weld County Department of Human Services w for the period from July 1,2012 through June 30,2013. D The following provisions, made this y2 day of c) , 2012, are added to the ret enced Agreement. Except as modified hereby, all terms of the/Agreement remain unchanged. w 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#1588508. 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. 070/)-a. i/ 1 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 ❑I)One round trip a week O1%)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? ❑ Basic Maint.)No participation required DI)Once a month ❑1'/)Two times month 02)Three times a month ❑2%x)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? 0 Basic Maint.)No educational requirements ❑l) Less than a ''/1 hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 ''/z) 1'/r2 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 DI)Less than 5 hours per week 011/2)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%:)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3/)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) DI)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3Y:) 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) ❑1)Less than 4 hours per month 02)4-8 hours per month 03)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. : :::::::; tt 7 n 4Pvi ' c i } A a�i,� `" w sn�s�, g.;a . t . . .dy �&.r '. l', ' 'V44 f 1 Ili � ,'; E� r.',2".', �' si, k v5,� ry ,ts%1�'7 :' . _. '� 11 -sR �earF' .. '' a x j [ 2 r_..�. : i$ \ k Y yI= i 3t t a .ni„ a �"vd ir � Lh£ WL ++?nl@s cTi ,, e:i, „a,,,,4.,illialivi‘441'fl P. 1.,_ �leav y = a i .n-k-,, , ;' `irt : ti. o �. , t* fi t Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ l: ❑ CI O O O Destructive of Property/Fire Setting ❑ ElCI ❑ CI O O Stealing ❑ CI 0 0 CI ❑ Self-injurious Behavior ❑ CI CI ❑ ❑ CI ❑ Substance Abuse ❑ ❑ ❑ 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 ❑ ❑ O O O O Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway El El 0 0 El El Sexual Offenses 0 CI ❑ ❑ CI CI 6 Weld County Addendum to the CWS-7 (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a.r I to this child k..��' � iv�vR�ai#i ^�d�' vkJ„ ��,3t�� a tc "C3 "r s "�� . s� k "*-5c ,tt5�`"₹� g',Fes. e t, -n.ti is G rp oA 1 '.Y If t i A..,� I t.F Y s s r>k'� n ' ± irk s t t Fsp, OAE 6 tits <n ' a16 r sr i s+: ' tc t F ' i.iZf- .i.. ii. -21. 'i�v�f ' '4 ',„1.1.:‘,..,., €2, ,a 'r k Yt}.I .� , a__ s ai $ .':i sr � t*x��r � tv�fitau S 4.'''-k. � .. e, fat ` v. n� a ,f`u 3 3 re,';i-_,..414.„:“,:.,,,54 ta.5.fi ,s i �z e a, ittatits -. -sib=',L 3-sive ;�a Inappropriate Sexual Behavior 0 0 ❑ 0 0 O O Disruptive Behavior ❑ ❑ ❑ 0 0 0 ❑ Delinquent Behavior ❑ 0 ❑ ❑ 0 0 0 Depressive-like Behavior ❑ 0 0 ❑ ❑ 0 0 Medical Needs (If condition iss rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 ❑ ❑ 0 0 0 Eating Problems ❑ 0 ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ 0 0 ❑ ❑ 0 0 Requires Night Care ❑ ❑ ❑ 0 ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ 0 0 ❑ involvement with Child's Family ❑ ❑ ❑ ❑ 0 ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) Ill ❑i ❑ 1'/z ❑ 2 ❑ 2'/ ID 3 El 3 Yz 7 Weld County Addendum to the CWS-7 • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE '711' 2,7,44-7q(igirafrier.4%1Y7i4; 4 ti � iu ' i n Y R as) "'' r x'`:3,.13 s}g.p [ T"" }- i�r I�i f Age 0-10...$16.32/day ($496/month) ^f0t} County Basic : -,,i Age 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) • A,a +Respite Care$.66/da p y ($20/month) $19.73 1 4.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 ==°y +$.66 Respite Care Total Rate=($23.67 day/$720 month)tit $26.30 2 4.66 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) -yap $36.16 3 1/2 '=_3 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down y r +5.66 Respite Care Total Rate=($40.11 day/$1220 month) tiit u&N Assessment/Emergency ' 7 $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7A • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld Count lerk to the Boar. WELD COUNTY BOARD OF SOCIAL �i ♦` SERVICES, ON BEHALF OF THE WELD a COUNTY DEPARTMENT OF HUMAN A� cM RVICES 1161 ,B I/ L //,/42ature Deput Jerk to the Boa .vhf, ( Protein AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Gomez, Oswald and Christina OF HUMAN SERVICES 7226 Matheson Dr. Fort Collins, CO 80525 v By: By: C u t*tQ4ure/D Provider's Signature/D By: Of 141O, Provider's Si ature/ at &O/3,4g// 9 Weld County Addendum to the CWS-7A /A (K1 U-I U/Y9) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, /, v?oit. by and between the Board of Weld County Commissioners, sitting as the Boar of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Gutierrez, Elisa and Hoffer, Christopher, Provider ID#1519595, 10101 W 13th St Rd, Greeley, CO 80634, 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 ao1/22 -ar1i/ LWS-/A(KIU-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 lei NJ-/A(K10-10/99) • 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 Bo, a�'°rr�� WELD COUNTY BOARD OF SOCIAL 1�1Li-do SERVICES, ON BEHALF OF THE WELD ODEPARTMENT OF HUMAN RVICE 1-6 Deput �C erk to the Board' Chair Signature AUG 2 9 2012 Phnom Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Gutierrez, Elise and Hoffer, Christopher OF HUMAN SERVICES 10101 W 13th St Rd Greeley, CO 80634 By: By: / gt�� Directo 'BSigna a/Date PPrroovidersSigne re ate By: / /q 'V( PO Provider's Signature/Date 3 ao/a-rill WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Gutierrez, Elisa and Hoffer, Christopher and the Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made this / day of /4044, 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#1519595. 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. aO/a 023, 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 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 01%)2 round trips a week O2)3-4 round trips a week. ❑2%)5 round trips a week O3)6 round trips a week O3%)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 01)Once a month 01%)Two times month ❑2)Three times a month O2%)Once a week O3)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''/2 hour per day ❑1%)'%hour a day O2) 1 hour a day O2 %) 1'/r2 hours per day O3)2'/2-3 hours per day O3%) 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 01%)5 to 7 hours per week O2)8 to 10 hours per week ❑2' ) 11 to 14 hours per week ❑3)Constant basis during awake hours O3%)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? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) 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. D1%)Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%) 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. O3%) 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) ❑l)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/intensit of conditions which create the need for services that a I to this child. ro T TT 'yP 4kl 4 yy kk 4 r y ., a �t /indue4�x h,, t( i f i �� .. y T4' '':+- ja+.c, r ro'� . ' f. ° �' y}. ay +x � ...s. .; ''` xC4'�,N ,. yp� a^ i to a+, a ! !f ' s sae e%.: i a9� h i s W $.,`�' +rte " ' f • ctill yT �?$4;N i7 v a F #4 lcIs 1 Aggression/Cruelty to Animals ❑ ❑ 0 0 0 0 0 Verbal or Physical Threatening 0 0 0 ❑ 0 0 0 Destructive of Property/Fire Setting 0 0 ❑ 0 ❑ O O Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ 0 0 0 0 Substance Abuse 0 El El 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ 0 0 Enuresis/Encopresis 0 ❑ 0 0 0 ❑ 0 Runaway O 0 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS- • ' (Exhibit B) ' WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a.'l to this child. N i .1 '' d k- ry e w i 4.:v,,,* k t:'. ,,,, ka M yz �n' ��q`" '0' r uV+ €k u. a rY 7,t v",ra t# ; 4 s f . a'F.'-v.m a s. vV' '=5m' i4 ', a.4 e. am s• a. s. :4i4x a ?'e „ap,t.. 5 +' v*z �,x,' m as r4 i, ra s ; "imsr tt Ezrior. pl.::„....,.? iiii y ,d5 ti ° ➢ ,, r .yE is d, e� .� .t •r,di ,,3:-..,, g.,c „ ! J k Y ..;. .. .. '. 'd.��.` a'�::a i�tia x4?ti+`v'�-,��, ,E°i� t. n."°µ v+.x Inappropriate Sexual Behavior 0 0 ❑ 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ 0 ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems O 0 0 0 0 0 0 Boundary Issues ❑ 0 0 0 ❑ 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education O 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'A ❑ 2 ❑ 21/2 ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7 4 (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Age 0-10...$16.32/day ($496/month) `I s County Basic Age 11-14...$18.05/day ($549/month) Maintenance _ Rate ILA Age 15-21...$19.27/day ($586/month) "°'-' +Respite Care$.66/day p ($20/month) Si..: $19.73 1 P Pk +$.66 Respite Care A. Total Rate=Ad ($20.39 day/$620 month) ..it $23.01 1 1/2 A. +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 , +$.66 Respite Care .` *t Total Rate=($26.96 day/$820 month) qw $29.59 2 1/2514 +$.66 Respite Care it Total Rate=($30.25 day/$920 month) . $32.88 3 +$.66 Respite Care ili Total Rate=($33.54day/$1020 month)HP 10- $36.16 3 1/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down o ( +$.66 Respite Care Total Rate=($40.11 day/$1220 month) ti=ut Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-i $ • 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 Elide BOUNTY DEPARTMENT OF HUMAN RVICES ap-tyw4O By: I i/ L.t i iiLA%4. , : t L _ _7 Deputy erk to the Boar•�C'I $ air Signature 2 9 2012 Proem Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Gutierrez, Elisa and Hoffer, Christopher OF HUMAN SERVICES 10101 W 13th St Rd Greeley, CO 80634 By: By: tLDate r's ate By: KZ; rovider's Signature/Date 0,76/07- 07S4 9 Weld County Addendum to the CWS-7A CWS-/A(KlU-lu/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, '7) QC)) by and between the Board of Weld County Commissioners, sitting as the Boar f Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Helmer, Sara, Provider ID#1547292, 3000 W 19th St, Greeley, CO 80634, 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 childrertat 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 02072-a3// LWb-/A(KIU-1U/99) -1. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. 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 LW,,-/A(1(10-10/99) • 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 Bo i WELD COUNTY BOARD OF SOCIAL s La SERVICES, ON BEHALF OF THE WELD .. IP% OUNTY DEPARTMENT OF HUMAN t: r RVICES By: y `� Deput ler to the Boar Chair Signature PlOrem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Helmer, Sara OF HUMAN SERVICES 3000 W 19th St Greeley, CO 80634 n 1 By: - By: ari o 34f / -t/ frICIL r 2-12-1 02 Director' Signature/ ate Provider's Signature/Date By: Provider's Signature/Date 3 &O/Q-d3// t WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Reimer, Sara and the Weld County Department of Human Services RECD AUG for the period from July 1, 2012 through June 30,2013. 2 0 2072 The following provisions, made this ! 3 day of , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of th greement 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#1547292. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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. 4D/ 6c$// 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? l3'%asic Maint.)Less than one round trip a week ❑l)One round trip a week 011/2)2 round trips a week 3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week )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'/z)Two times month 02)Three times a month ❑2'/z)Once a week 03)Two times a week ❑3%z)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? asic Maint.)No educational requirements DI)Less than a''/z hour per day ❑1%) '/x hour a day 2) I hour a day 02 ''/z) 11/2-2 hours per day 03)2'/,-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ist Basic Maint.)No special involvement needed 01) Less than 5 hours per week ❑1%) 5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week ❑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 01)3 to 4 hours per week 011/2)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%)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. 4 (i.e. mutual care placements.) 1)Face-to-face contact one timeper 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. 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? Not needed or provided by another source(i.e. Medicaid) DI)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- S- (Exhibit B) • • WELD NEEDS BASEDCOUNTYCARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a:::::,to this child. k:i3uH,.'° ni-.upa byf .5 e#T t.A } '..,.. '"a'u in;t�� „� sue• � itfa ai v�*.� 'fe`u' �'"'a .i' 5* t `'gyp x{.... ,."s' .it ` . il aliftialeetp'.3�T S-'=' i w '6 e._ °'�sta'' ' �a lPu va". 'S'9,'kr�`v'^'�.. . v a�P*tt:.�.. a=..*'.``, ...1ff'i4 nvXsm. S`+ Aggression/Cruelty to Animals S��7( El ❑ ❑ 0 ❑ Verbal or Physical Threatening �l�r o ❑ 0 0 0 0 Destructive of Property/Fire Setting g 0 0 0 0 0 0 Stealing I ❑ 0 0 0 0 0 Self-injurious Behavior 0 0 0 0 0 0 Substance Abuse R 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 Enuresis/Encopresis 0 0 0 0 0 0 Runaway A 0 0 0 0 0 0 Sexual Offenses 0 0 0 0 0 0 6 Weld County Addendum to the CWS (Exhibit B) WELD COUNTY DUB • NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED fi��ggw Please rate thebehavior/intensit of conditions which create the need for services that a..l to this child. bi . R a ''4 S"" uaamvv s" . 'e gsgS `ys which ;: .. .:1,,,,,,.14-,,• ::. 4.& r ' s 3�as- v °'S) �. I E 4 1 1 f st i ' t �.v ' 1-41---a,,,-,+4,,,- b Jests: , L Li inil v+ kA ll 4_i Y•- a Inappropriate Sexual Behavior O ❑ O O O O Disruptive Behavior PIN ❑ 0 ❑ O O ❑ Delinquent Behavior P( O 0 0 0 0 0 Depressive-like Behavior P O 0 O 0 O 0 Medical Needs (If condition is rated"severe', ❑ ❑ El Ell O O please complete the Medically fragile NBC) Emancipation 0 0 0 0 0 0 Eating Problems 0 0 0 0 0 0 Boundary Issues ti O 0 0 0 O O Requires Night Care L l�J J r brit 0 0 O ❑ O 0, 0 ea Oh n.AI tit Education X ❑ ❑ ❑ 0 0 0 Involvement with Child's Family 0 0 0 0 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/ • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Are rh.,2,1UsalgeniplikilyipwevitaC Age 0-10...$16.32/day ($496/month) County Basic 1.44 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) $23.01 1 1/2 #IN +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 112 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care lisie Total Rate=($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) rem 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) rai Assessment/Emergency CUNI $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-71 • 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 C •• WELD COUNTY BOARD OF SOCIAL 4 s Lz SERV , BEHL O T t OUNTYICES DEPARTMENTON AF OFF HHEUMANWELD r . a RVICES tul By l 4W / ;►_I � + t4 fh ' fit y' Depu Cler to the Boar air Signature Protem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Heimer, Sara OF HUMAN SERVICES 3000 W 19th St Greeley, CO 80634 p By: By: 1� j C� 1� O 4-2—/, C Dire pt r s Signat e/Date Provider's Signature/Date By: Provider's Signature/Date c/c 9 Weld County Addendum to the CWS-7A L W S-/A(KIU-1 U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, JO/y l/2O/;_ 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, Hoeft, Kimberly, Provider ID#1603004, 5551 W 29th Street, Unit 712, Greeley, CO 80634, 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 c9eria-a.4// LWS-/A(Klt)-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 L W J-/A(KW-10/99) - 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 B.-�'.'�� ♦ WELD COUNTY BOARD OF SOCIAL s ILa SERVICES, ON BEHALF OF THE WELD OUNTY DEPARTMENT OF HUMAN • " �i RVICES x1‘- By. l/i"7Z' Ls�:��-! / !/� y (Dep Clerk to the Boar .i Chair Signature AUG 2 9 2012 pmtem Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hoeft, Kimberly OF HUMAN SERVICES 5551 W 29th Street, Unit 712 Greeley, CO 80634 By: By: ✓v...afrx 7-as-1O- rector's ignature ate Provid 2tSat By: 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 Hoeft, Kimberly and the Weld County Department of Human Services for the period from July 1,2012 through June 30, 2013. The following provisions, made this I day of T I , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the)greement 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#1603004. These services will be for children who have been deemed eligible 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. a?O/a°- 634 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 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 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 'A)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? Basic Maint.)No participation required DI)Once a month ❑1%n)Two times month 2)Three times a month ❑2%z)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 of special education plan? eg Basic Maint.)No educational requirements 01)Less than a 1/2 hour per day 011/2)1/2 hour a day 02) 1 hour a day 02 %) I'L-2 hours per day ❑3)2''/-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ® Basic Maint.)No special involvement needed O1)Less than 5 hours per week ❑1%)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑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 01)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'/)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? rg0)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- (Exhibit B) • WELD COUNTY DHS NEEDS R BEHAVIOR BASED ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that al 81 to this child. 5 9 ,,,,,,:41'. b B1 c.ti �� } t,,:).._„;?,,,,9 A • B t tineitativogintik. xa • a { cc.-^ "'$ ..47 . +tt. x y2 }h P • x •�e ka `a '� . -�.aa 'm*. s. °°i`+:`,' i+ tak ^q"�"a k a ;'s!..C �'.'.'v.in..: + � Aggression/Cruelty to Animals ❑ 0 0 0 0 0 Verbal or Physical Threatening X 0 0 0 0 0 0 Destructive of Property/Fire Setting itt1O 0 0 0 0 0 Stealing X 0 0 0 0 O 0 Self-injurious Behavior 0 0 0 0 0 0 Substance Abuse IRi 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ] Y! ❑ 0 0 0 0 El Enuresis/Encopresis X' 0 0 0 0 0 0 Runaway NI 0 0 0 0 0 ❑ Sexual Offenses ilf 0 0 0 0 0 0 6 Weld County Addendum to the CWS • • (Exhibit B) • • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that al.1 to this child. P ' '.. '₹ i' . 2igall x`v�s K '�`ryfrv, .a"' .3. a , t a i}sv. °i-t"�' . ,t `a+y �+ ��.,*" . a'u " a F i.. 5 t rd 5K 3 F ', paat°E . ':t � 4 I i 3�. n fs 4 k -5 § `IS' '+ ;74. 1' ,++ re ..IliV 33SIA g A \I ' x,' '3 ya,ls f .:4 a :i. �' '. s:}.7,":,,,j,;.: va v r '.C.'-'kk +g A f, rsta>a�, p., „ vaigt r"r * .+ r " `°du 3, a3r!'.'43:''',!.*'yak d t. t5 'se733;* x'r9 eti u.;ru '" a +�. ;^'.r"_, � . .., ;< :, w. Inappropriate Sexual Behavior ❑ ❑ 0 0 0 0 Disruptive Behavior P ❑ ❑ 0 0 0 0 Delinquent Behavior 0 ❑ ❑ 0 0 ❑ 0 Depressive-like Behavior ❑ ❑ 0 0 0 0 Medical Needs gS4'nen —s (If condition is rated-severe", ❑ 0 4 ❑ 0 0 0 t al:�rt please complete the Medically `rz_er -W+ 1 fragile NBC) •CIMCI•t s VISE VS Emancipation ❑ ❑ 0 0 0 0 Eating Problems A ❑ 0 0 ❑ ❑ 0 Boundary Issues 114 0 0 ❑ ❑ 0 ❑ Requires Night Care 0 ❑ ❑ ❑ ❑ 0 Education 0 ❑ ❑ ❑ ❑ ❑ 0 Involvement with Child's Family ❑ ❑ ❑ ❑ 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 $ l'/z ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'/2 7 Weld County Addendum to the CWS (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Age 0-10...$16.32/day ($496/month) County Basic SO 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 itt Total Rate=($40.11 day/$1220 month) AssessmentiEmergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-1 Y 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 �4 SERVICES, ON BEHALF OF THE WELD %La�� COUNTY DEPARTMENT OF HUMAN ERVICES By' I�IL/L/ ; �� O'r :-,�Y: —L* Depute Clerk to the Bo Z� . ( Chair Signature lithium AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hoeft, Kimberly OF HUMAN SERVICES 5551 W 29th Street, Unit 712 Greeley, CO 80634 BY: By: _ /h. ,1 7 �S Co n Directo 's Sign e/Date Provider's Si:na a/Date By: Provider's Signature/Date o/3 07,V7 9 Weld County Addendum to the CWS-7A l-W S-/A 11(1 U-I U/Y9) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES • 4 AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 3"4l 4 Services, and between the Board of Weld County Commissioners, sitting as the Board of Soci Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Maronek, Dennis and Patricia, Provider ID#1520627, 4860 Eagle Crest Blvd, Firestone, CO 80504, 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. 1 017,0k2 -aS// (.WS-/A(KIU-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 LWS-/A(KlU-lU/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 E.IL SERVICES ON BEHALF OF THE WELD 1� 42) OUNTY DEPARTMENT OF HUMAN RVICES / wJ�11�sf1/42 .' By: I /��t/. ; L• Iw //LW? Deput er to the Boar. « ' � ' Chair Signature AUG 2 9 2012 , PITHJ Potent Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Maronek, Dennis and Patricia OF HUMAN SERVICES 4860 Eagle Crest Blvd Firestone, CO 80504 By: By:Q( '�vw2 \)�� OtICt Dire`o 's Sign re/Date eider's Signaturree//Date Provider's Signature/Date 3 &t/G-O2-V/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Maronek,Dennis and Patricia and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this 3 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#1520627. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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. tea/07 02a4 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' 9 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 ❑I)One round trip a week 011/4)2 round trips a week ❑2)3-4 round trips a week. ❑2'/z)5 round trips a week 03)6 round trips a week ❑3'/z)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? 0 Basic Maint.)No participation required ❑I)Once a month ❑1%z)Two times month 02)Three times a month 02%)Once a week 03)Two times a week 03%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular a special education plan? 0 Basic Maint.)No educational requirements 01)Less than a'/,hour per day 011/4) 1/4 hour a day ❑2) 1 hour a day 02 %) 1'/z-2 hours per day 03)2'/z-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the 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'/z)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedit 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 I. How often is CPA/County case management required?(Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 011/4)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'/z)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) DI)Less than 4 hours per month ❑2)4-8 hours per month 03)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/intensi of conditions which create the need for services that a..I to this child. ;:gp 1_/kr I); d f �4 .'i" t Yx.:,4.''t j=P-L. $t ,' Y g! ytA "," S yy ri.- I va i? �3 .:4;1134j3"3:+33.133:3¢ ,y a 't`e x' t.:§ ' 213;03334 klitrtale i'tr:.. A t o- g k , t'as'= 39.", x"Em t r.', . ... . ,.. ... }.. :,±x Aggression/Cruelty to Animals ❑ ❑ ❑ 0 0 0 0 Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ 0 0 ❑ 0 0 Substance Abuse O 0 0 ❑ 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 0 0 0 0 Enuresis/Encopresis O 0 0 0 0 0 0 Runaway O 0 ❑ 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/mtensrty of conditions which create the need for services that a'.1 to this child. rate C1/4):A.'1,4—a }� t fi xE a z m., ! . g!.y., , .. sd a +�* ° 1' 1 t7 E t! isi 1 d kk'��:elle 5 E' x ` a 5o-E tin d Ri & to � x_� ■■�'n �' t'�.i.'.� �t E � .�_: .a� 'r ,- *rx S ''' v` n x S'eY` t"v tr , E tE „ R+ �� inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior O 0 0 0 0 0 0 Depressive-like Behavior O 0 0 0 0 0 0 Medical Needs ❑ 0 0 0 0 ❑ ❑ (If condition is rated"severe", please complete the Medically fragile NBC) Emancipation O 0 0 0 0 0 0 Eating Problems ❑ ❑ ❑ ❑ ❑ 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ ❑ 0 0 ❑ ❑ 0 Involvement with Child's Family 0 ❑ ❑ 0 0 El CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 El PA ❑ 2 [7] 2'/x ❑ 3 ❑ 3''/ 7 Weld County Addendum to the CWS (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 471: k mss- e re y 1. 9ar . '...4441;7; rerlanagelEPT's,:%ffilitittrtgiti Pa:tSiaiiraliiihin A•- r-1•...$1.. /•• $4••/m•nth County Basic dk A•e 11-14...$18.05/da $549/month Maintenance Rate bl 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) EDO $29.59 2 112 • +$.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-(6 ate=($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: Weld County Clerk to the Bo. : WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD L11$10) UNTY DEPARTMENT OF HUMAN fC_"" a �C �VICES nal rig By ;._.ui i t i' '� %�� `i' • —V' Deputy��erk to the Board�►" � Chair Signature ?rorem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Maronek, Dennis and Patricia OF HUMAN SERVICES 4860 Eagle Crest Blvd qq //�� Firestone, CO 80504 By. UJV.' By: QVIWCWAal01) L o ty Dire tor's Si azure/D e Provider's Signature/Date By: a ce /478454 Provider Signature/Date ,7(2/O1-- 9 Weld County Addendum to the CWS-7A C W S-/A tKI U-1 U/99) • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 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, Martinez, Andrew and Jeanna, Provider ID#1585195,4404 Monte Cimone St., Evans, CO 80620, 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. 11ttff� 10. To allow representatives of the County Department to visit the foster hb&eel o Ie�t.. cttiltllat any reasonable time. 1 6719a - c 3/, LWS-/A(KIU-fU/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 C W S-/A(1(10-1V/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 Boare��' 1 WELD COUNTY BOARD OF SOCIAL sL®%•ERVICES, ON BEHALF OF THE WELD UNTY DEPARTMENT OF HUMAN 1/42= VICES itbt By: •iii��' ' Ci �,y !/ 2 Deput ' erk to the Board ` ��n i �, Chair Signature AUG 2 g 2012 'totemApproval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Martinez, Andrew and Jeanna OF HUMAN SERVICES 4404 Monte Cimone St. Eva , CO 80620 By: By: Director' Signatu /Date Provider's S nature/Date By: l P ovider's Signature/Date / 7-11-la 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Martinez, Andrew and Jeanna and the Weld County Department of Human Services for the period from July 1,2012 through June 30, 2013. The following provisions, made this day of , 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#1585195. 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. 6,70/o?-AS/ j 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 O1)One round trip a week ❑1/)2 round trips a week O2)3-4 round trips a week. O2%)5 round trips a week O3)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 DI)Once a month ❑1%)Two times month O2)Three times a month ❑2%)Once a week O3)Two times a week O3%)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'%) '/z hour a day O2) 1 hour a day O2 %n) 1%z-2 hours per day O3)2'/z-3 hours per day O3%)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 ❑I)Less than 5 hours per week ❑1%z)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 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 feeding, bathing,grooming, physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week O2)8 to 10 hours per week O2%) 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%)Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3)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) DI)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-7A (Exhibit B) WELD COUNTY DHS • NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. e _ � �iz{ t��m* �a�.ai^T 1 } ,.. as, elf fr1�']r SS 4 �'"_. n '-'7::-.77'.;" ' ` I. s�`�, �,A°9°�s�"a�'? �tY .,.�. .. .. _. .e . . . +,`:a:�` Aggression/Cruelty to Animals 0 ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 ❑ ❑ ❑ 0 ❑ ❑ Destructive of Property/Fire Setting 0 0 0 O O O O Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior 0 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 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ 0 0 0 0 0 Sexual Offenses 0 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS ' • NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a'.1 to this child. ;.:),2t:',.:::_ V , _. . {y1 4� r q ' p y I .S.;R k�f $.{ '/-":-...'''.-.: '.r S - { r4 54 4 y 6 � 9 ! k''' : : 4 t ° ['',T1.1-. f Y C {14 ..+k....r .e r x l ti { r* t . °x.�a" .. 4 .... :i t+...�.a es.. ens. inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ 0 ❑ 0 0 0 0 please complete the Medically fragile NBC) • Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ 0 0 0 0 0 ❑ Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑i ❑ PA ❑ 2 ❑ 2'A ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE . 4^� t e� .Y6• t t3 A39 i5 l a i Psa � 1.;ty''� Ni k't 4 S tL.!. t �rv:;1l m�mm.aS'� .;' 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 ($586/month) @ r. +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 21/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) kek $32.88 3 +$.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 rtjr Effective 7/1/2008 8 Weld County Addendum to the CWS-7A . SIN 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 S La, COUNTY+,SERVICES DEPARTMENT OF HUMAN Depuj lerk to the Bo`�✓ : ? Chair Signature l Protem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Martinez, Andrew and Jeanna OF HUMAN SERVICES 4404 Monte Cimone St. Evans, CO 80620 �7 B • By. o my Dice tor's Si ture/Da Provider's nature/Date By: /lLA- /Vl ovider's Signature/Date a©/a- O2Si/ 9 Weld County Addendum to the CWS-7A (-WS-/A(K I U-I U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT REC'D AUG 2 p 2012 1. THIS CONTRACT AND AGREEMENT, made this date, 5 by and between the Board o of Weld County Commissioners, sitting as t of ocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Mauk, James and Harriett, Provider ID#1537621, 3620 Dilley Circle, Johnstown, CO 80534, 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 c)20ia-a-' L W J-/A(K1 U-I(1/`J9) 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 U W S-/H(KW-1U/V9) 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 Bo. WELD COUNTY BOARD OF SOCIAL re Lam SERVICES, ON BEHALF OF THE WELD ��OUNTY DEPARTMENT OF HUMAN RVICES 9J4ci1VT1: By: 7 Deputy ' lerk to the Board ,t,�j Chair i nature r m AUG 2 9 2012 Pro e Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mauk, James and Harriett OF HUMAN SERVICES 3620 Dilley Circle Johnstown, CO 80534 By: \,-/ By: Directo 's Signature/ to Provider's Si n ture/Date By: (1:1k /�}/ 77 �z� Provi Signature/Date 3 6P'°ia-0734 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Mauk,James and Harriett and the Weld County Department of Human Services for the period from July 1,2012 through June 30,2013. The following provisions, made this /5 day of , , 2012, are added to the referenced Agreement. Except as modified hereby, all to ofthe--A eement 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#1537621. 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. &()/a _a34 1 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 01)One round trip a week 011/2)2 round trips a week ❑2)3-4 round trips a week. 02%) 5 round trips a week 03)6 round trips a week ❑3'/)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? O Basic Maint.)No participation required DI)Once a month ❑1/)Two times month 02)Three times a month ❑2'/)Once a week 03)Two times a week ❑3'/)Three times a week or more Comments: P 3. How much time is the 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 ❑1) Less than a '/hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 '/) 1'/-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 01)Less than 5 hours per week ❑1'/:)5 to 7 hours per week 02) 8 to 10 hours per week ❑2'/) I I to 14 hours per week 0 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 feedir bathing,grooming,physical, and/or occupational therapy? O Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/) 5 to 7 hours per week 02) 8 to 10 hours per week 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.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. 011/2)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? ❑0)Not needed or provided by another source(i.e. Medicaid) DI) 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/intensit of conditions which create the need for services that a..ly to this child. T ari'4745;;',:i '1 t"e'.416,41 z, I, �,t i y3 ,, l..1-!-.7,1: 1 1 1�i Ol.. S '•.e$ -' t "!9", -,�`PZ y� %S kfi k' v�a i. fis g wI h ' rs 4 .73 6 . & m3JrerQ �!ai 3zF t .� �y ri rt t a b ox4 tt ttir:` u 6c.- -r mss 't:it GCy x. 4p� -.t. .-ii; "" 4x ;p ` 9, ``rt' � :. t�.` °`l"`� v§ '0i d r b I r*3 k�, as tt , «a ,y w*} a :',1:;1...; s. r t, 's^ . ai 6 Aggression/Cruelty to Animals 0 0 El El El 0 El Verbal or Physical Threatening ❑ 0 ❑ 0 ❑ 0 0 Destructive of Property/Fire Setting 0 0 El ❑ 0 0 0 Stealing ❑ ❑ 0 0 ❑ El El Self-injurious Behavior o ❑ El El El El 0 Substance Abuse ❑ ❑ ❑ 0 0 El 0 Presence of Psychiatric Symptoms/Conditions ❑ El ❑ ❑ 0 0 0 Enuresis/Encopresis El ❑ ❑ 0 0 El El Runaway O 0 El El El 0 0 Sexual Offenses El ❑ El 0 0 ❑ ❑ 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 a..ly to this child. ,�. ja ,4 ,4:. °' ' �t,,s4 ,4,,b y-I„",tr I•?s �µ t'm �i • -, , , vY a" a.a 9 "c�` �#, i r` ' r,y€u'0 7. T"4."'rS A t t ;;$.s 4 : ; :s fd • " p. fey+: m!axyam'*` ° kif..v,gg v�v PoPCb �' 'a <.µ' in;j ' - ti: s i ,4v ° s 'd { «` , "� . ° . - h'''� ' wZkr. *M+ `: $ y. '° 7i}4-4:-,, Y ''Pk w *- itp 1.'7 ',1 `', y 744 rm * 'l" s ,-., u k y '' • ah :E `'%:rx z cP *t: max ' r, 1 4 .4,4144:52.,...•,;.;" 4 s f bst•it 1 '� !it - x :4 ( : a .' .a I ,} 'E vzr t :b tr "'� ''~+9r°ayp"Sx m. '' g es.;' 'iz �: ., .. • s�kaliiaet"3 ..,<.,1,:t: .Ssh' ,,', '_'.x1:k,:::: ,I",k„4t! ' Inappropriate Sexual Behavior 0 0 0 ❑ 0 0 0 Disruptive Behavior ❑ 0 0 0 ❑ 0 0 Delinquent Behavior ❑ ❑ 0 ❑ 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", El ❑ ❑ ❑ 0 ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ 0 0 0 0 0 ❑ Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/ ❑ 2 ❑ 21 ❑ 3 ❑ 3'h 7 Weld County Addendum to the CWS-7 (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE n a s�y��n Aqe 0-10...$16.32/day ($496/month) 024, County Basic St Aqe 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) FA $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 r +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 AAA +$.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) WrI �.d Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS- • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD #4sAcezom`OUNTY DEPARTMENT OF HUMAN RVICES ,' �N Deputy lerk to the Boar r► /1►4 '>/ Chairsm tureAUG 2 9 2012 Approval as to Substance: �,• PROVIDER WELD COUNTY DEPARTMENT Mauk, James and Harriett OF HUMAN SERVICES 3620 Dilley Circle Johnstown, CO 80534 By: By 9 ! Co Direct 's Sign re/D Provider's Signature/Date PriT4771- -/5" Pto er's Signature/Date/ oco/0.,70/ a2//'- a2i 9 Weld County Addendum t e CWS-7A U W S-/A t to u-i u/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES ' AND FOSTER CARE FACILITY AGREEMENT 1aUL I( 148 deIVRACT AND AGREEMENT, made this date, 'J—I 112— 2OIlbyl/dflcrtwfe nn the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf 6£ 2$ the Weld County Department of Human Services, hereinafter called "County Department"and, McGee, Donna, Provider ID#1539853, 1649 31st Ave, Greeley, CO 80634, 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 &O/c? ahct// LWS-/H (KLU-IU/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-IA(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 WELD COUNTY BOARD OF SOCIAL � SERVICES, ON BEHALF OF THE WELD 5./ :k'' COUNTY DEPARTMENT OF HUMAN y � � ERVICES �� 661 I By. fr By: Deput Clerk to the Boa U.S Chair Signature AUG 2 9 2012 Pram Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT McGee, Donna OF HUMAN SERVICES 1649 31st Ave Greeley, CO 80634 {�� l7 By: By: Qder'sSnet /l7 fect 's Signal aDate By: Provider's Signature/Date 3 (YO/O2-0 i/ • WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between McGee, Donna and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this 11 day of 4A.A1. , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the Agteement 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#1539853. 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. 1 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 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 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 ❑I)One round trip a week 01%)2 round trips a week O2)3-4 round trips a week. ❑2%z)5 round trips a week ❑3)6 round trips a week O3%)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 ❑l)Once a month 01%)Two times month ❑2)Three times a month O2%)Once a week O3)Two times a week O3%)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 DI)Less than a ''/a hour per day ❑1%)'%hour a day O2) 1 hour a day O2 %z) 1'%-2 hours per day O3)2'A-3 hours per day O3%)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 01) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 11 to 14 hours per week ❑3)Constant basis during awake hours O3%)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? 0 Basic Maint.)0-2 hours per week O1)3 to 4 hours per week ❑1%z)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week O 3%)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. O 1%) Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. O3%) 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? O0)Not needed or provided by another source(i.e. Medicaid) ❑I) 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/intensit of conditions which create the need for services that a.i i to this child. 'i' 4'4. # v _ �tj s F fry: t I l.':,, F r x x, y Y' t74. -p' c &. h to ₹a ifik 40.41 ,iiu''.- k C 1 '' . r d ! Pill } `' ' *��'' � 3;. i` 8 fE a.� A as s. :::: ry f d e � ' �.._.- 3i�r "h;, ,„s:i. F ,�a � ; Por : '' ' ' fit t F � 4,41 �� d ' ,e.4 � �;::,a�"Ys t'7; 4xM° 'l1k -+t.,,..t ',. 4: 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 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 ❑ 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ 0 0 0 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ 0 0 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 a..I to this child. im� sa��,>+a`* y.�,rm ,� � � �) .r .W, c�...>°. �a. .s y � ,.s°. ; Inappropriate Sexual 0 ❑ 0 0 0 0 0 Behavior Disruptive Behavior ❑ 0 0 ❑ 0 ❑ 0 Delinquent Behavior O 0 ❑ 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ 0 ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 0 0 Eating Problems ❑ 0 ❑ ❑ ❑ 0 0 Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care ❑ ❑ ❑ ❑ 0 0 0 Education ❑ ❑ ❑ 0 0 ❑ 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2'A ❑ 3 ❑ 31/2 7 Weld County Addendum to the CWS ' (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 4;.1','1 , % ? fiS. R`f'� 1; 1 k d ��, �- tx A.e 0-10...$16.32/da $496/month County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate A.e 15-21...$19.27/da $586/month • +Respite Care$.66/day ($20/month) $19.73 1 filte +$.66 Respite Care fzi Total Rate= ($20.39 day/$620 month) $23.01 1 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) &y $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) 4i $29.59 2 112 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 112 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) Itre fah 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) tclt Assessment/Emergency Rate -;x $30.25 day/$920 month(Includes Respite) 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 �!� SERVICES, ON BEHALF OF THE WELD �. ,� ►�S UNTY DEPARTMENT OF HUMAN -"Sr- �. .1''1�,,� VICES R . � By: ft Deput lerk to the Boards raj �� Chair Signature �` .• proton AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT McGee, Donna OF HUMAN SERVICES 1649 31st Ave Greeley, CO 80634 By: t Dire By: PM/W(1R_ 7-17 P Co t# c10 s Signat i /Date Provider's Signature/Date By: Provider's Signature/Date 0a2/d- cc.3// 9 Weld County Addendum to the CWS-7A UWS-/A (KIU-IV/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 1 (t3)(? _ by and between the Board of Weld County Commissioners, sitting as the Board of S ial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department"and, Mena, David and Marie, Provider ID#1510691, 2905 41st Ave, Greeley, CO 80634, 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. 1 070/2-02S'' L W 5-/A(K I U-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 Boar s WELD COUNTY BOARD OF SOCIAL /� �[L �s SERVICES, ON BEHALF OF THE WELD � � ��-1� ��` OUNTY DEPARTMENT OF HUMAN J RVICES R �rR9 Depu lerk to the Boa j ` V Chair Signature 1 I Protein AUG 2 9 2012 Approval as to Substance: """ PROVIDER WELD COUNTY DEPARTMENT Mena, David and Marie OF HUMAN SERVICES 2905 41st Ave Greeley, CO 80634 By: By: '71g31 IZ irector's ignature/ ate P �der's '.nature Dat- By: at /I li aZ) R— io id-" Signature/Date 3 &C/& c3/, WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Mena, David and Marie and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this 3 3 day of U , 2012, are added to the referenced Agreement. Except as modified hereby, all terms o the greement 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#1510691. 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. 1 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 DRS 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 01)One round trip a week ❑1%)2 round trips a week O2)3-4 round trips a week. ❑2'/:)5 round trips a week O3)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 O1)Once a month 01%)Two times month O2)Three times a month ❑2'/:)Once a week O3)Two times a week ❑3%i 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? O Basic Maint.)No educational requirements 01) Less than a ''/2 hour per day 01%) ''A hour a day ❑2) 1 hour a day O2 ''/) 1'/,-2 hours per day O3)2''A-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 On Less than 5 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) 11 to 14 hours per week ❑3)Constant basis during awake hours O3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin1 bathing,grooming, physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week 031/2)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one timeper month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%a)Face-to-face contact three times per month with child and occasional crisis intervention. O3) 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) ❑l)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 behavtor/tntensit of conditions which create the need for services that a..1 to this child 1. �viiixi� �t ��{ 3.•. ,n aI �M ty 4.1". ! Y Irt ' 9 4gt i 4 ..- * " l 4 a - - .',.' ti ,.,v �ssr ., sex t'` w .# a�°+..a; r :. ' �o . acv '.. x'cse ,i₹,. s a ¢ a , is .�:. e-./.4/:z14-14:-::::-"1-:4 yj ii._al. :loll II S % lit i, k�4�1 „v .., 'n'axi Aggression/Cruelty to Animals ❑ 0 0 ❑ 0 ❑ 0 Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 El 0 0 Stealing 0 ❑ 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse 0 ❑ ❑ 0 ❑ 0 ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑ ❑ 0 0 Enuresis/Encopresis ❑ 0 ❑ ❑ ❑ 0 ❑ Runaway ❑ 0 El ❑ ❑ 0 ❑ Sexual Offenses 0 0 0 ❑ ❑ 0 0 6 Weld County Addendum to the CWS- (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE• BEHAVIOR ASSESSMENT CONTINUED ('�.. Please rate the behavior/intensit of conditions which create the need for services that ar r I to this child. it } tri a'"r-". �r .�Tg ,r.�d a.s5` ,...aL'67;" �m ) ,aya- . a "� 5: 1z Pi"R "''•.Ta var. fi 'I'' t i ' r sA . ,' e ,,,,i frw pq + 9 1 � �" ,rgs.. 1 ,' ' ' �' mid _ M1 . xA aF. -. :'''P$ 6.x, s f t}?- .. R SES.fi f Nn 4. Gtg �$ aa�a ,�...A..�,t $ Arvr rry� � .,�iRW�3 .id" 6 �" L` 9 >€ �� t y r. aT�r ''at ft f 4 �.. ' ; .—;.„...m.,479.1,..ay: eA Inappropriate Sexual Behavior ❑ ❑ ❑ 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 ❑ 0 0 0 Depressive-like Behavior O 0 0 0 0 0 0 Medical Needs (If condition is rated"severe ❑ ❑ 0 0 ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation O 0 0 0 0 0 0 Eating Problems O 0 0 0 0 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/ ❑ 2 ❑ 2'h ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS' (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Twk t ti;a+1 i h ,,,,a $ r ls°tstS ,{ 2;1;,.'',.‘›...34,.:41:.&).:•.'y q' —1-7.341.y9441 4i v�` Alit:4t.& k , k 4 ..4 '31 h .Yt r 'k e �yvcar §{t nP ti(. f Y Aqe 0-10...$16.32/day ($496/month) County Basic A.e 11-14...$18.05/da $549/month Maintenance Rate Age 15-21...$19.27/day ($586/month) ItIggi +Respite Care$.66/day ($20/month) ell $19.73 1sit4W11 +$.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) $29.59 2 1/2 41 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 7 ,4 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down iii +$ Total Rate=($40.166Respite1 day/$12Care20 month) , M„ '3,,F-11:. Assessment/Emergency w1'. $30.25 day/$920 month(Includes Respite) Rate N d Effective 7/1/2008 8 Weld County Addendum to the CW S-i •. •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 E.,La COUNTY DEPARTMENT OF HUMAN RVICES _� By a% %' i �i� a �: .r ' y: Deputy ' lerk to the Boa�y r n hair Sig i atwe Ptotem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mena, David and Marie OF HUMAN SERVICES 2905 41st Ave Greeley, CO 80634 By: y` ICo tyDirk4jQgurei4 Pro ide s Si ature/Da e By: �ny C ` Provide s Signature/Date o?.ia3// 9 Weld County Addendum to the CWS-7A l: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, I Are/L by and between the Board of Weld County Commissioners, sitting as the Boa41 of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department"and, Middleton, Brian and Deborah, Provider ID#1537851, 2418 W. 24th St Rd, Greeley, CO 80634, 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. 0 7. Not to accept money from parents or guardians. a 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. t'" 10. To allow representatives of the County Department to visit the foster home and to sege child at any reasonable time. • 1 I:WS-/A(KIU-IU/99) f _ 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 LWS-/A(KW-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 Count rk to the B• f•; fl � WELD COUNTY BOARD OF SOCIAL •/c 1tCC�e D `AERVICES, ON BEHALF OF THE WELD d0 UNTY DEPARTMENT OF HUMAN !��r'sr('�j;Q RVICES / ab �l1 • L �l By: �✓ _ i/r'►�.�, ./�:�._t�4'._ J y: Depu lerk to the Board %` ,! Chair Signature AUG 2 9 2012 Protein Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Middleton, Brian and Deborah OF HUMAN SERVICES 2418 W. 24th St Rd Greeley, CO 80634 By: By: `, '4lI a Director Signatur / ate Provider's i t ate By: roZi er's Sig ure/Date 3 ,?o%l- a�3// WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the"Agreement") between Middleton, Brian and Deborah and the Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made this 17 day of A.0.,s j< , 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#1537851. 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. a1ia- 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 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 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 01)One round trip a week 01%)2 round trips a week ❑2)3-4 round trips a week. ❑2'/,)5 round trips a week O3)6 round trips a week O3%)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 01)Once a month ❑I'/)Two times month O2)Three times a month O2%)Once a week O3)Two times a week ❑3'/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 or special education plan? 0 Basic Maint.)No educational requirements ❑1)Less than a '/,hour per day ❑1%) %hour a day ❑2) 1 hour a day O2 %) 1'/:-2 hours per day O3)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 ❑1)Less than 5 hours per week ❑1'A)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3'/s)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week O1)3 to 4 hours per week ❑1%:)5 to 7 hours per week O2) 8 to 10 hours per week O2%) 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.) ❑I)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. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3)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) ❑I)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-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that as 81 to this child. .. t . q » l g ..h } Aggression/Cruelty to Animals ❑ ❑ 0 0 0 0 0 i Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ 0 ❑ ❑ ❑ 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior El 0 0 0 0 0 0 Substance Abuse ❑ 0 ❑ ❑ 0 ❑ 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 ❑ 0 0 Enuresis/Encopresis ❑ ❑ 0 0 ❑ 0 ❑ Runaway ❑ 0 ❑ 0 0 0 ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..I to this child. 2 # --, . ,„ Y Q S y P f i 4 � j 1 I '1• i ei Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior O 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ 0 ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ 0 D 0 0 Eating Problems ❑ 0 0 0 ❑ 0 0 Boundary Issues ❑ ❑ ❑ 0 ❑ 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ ❑ 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/4 ❑ 2 ❑ 2/ ❑ 3 ❑ 3''/ 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE • , of 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) $19.73 1 4 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 r. ' +$.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) sE 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency itit. $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7A • 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 t WELD COUNTY BOARD OF SOCIAL a SERVICES, ON BEHALF OF THE WELD ,BOUNTY DEPARTMENT OF HUMAN RVICES By: B y: Deputy erk to the Board �"�.r Cha Signature Proem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Middleton, Brian and Deborah OF HUMAN SERVICES 2418 W. 24th St Rd Greeley, 80634 11.1 By: By: 5 k( `W'a/ia Co y Directors Sign at re/Dat Provider's Signature/Date By: Provider's Signature/Date aoia-aSi/ 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-10/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES • AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, I' ,-6/l_ by and between the Board of Weld County Commissioners, sitting as the Boar of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Miller, Pamela, Provider ID#1587465, 5151 W 29th Street, Unit 2004, Greeley, CO 80634, 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. REC'D AUG 2 0 2012. 1 ��ia (28// LWS-/A(KIU-IU/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 LWS-/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 B //��€ OTYDEPARnUMAN WELD COUNTY BOARD OF SOCIAL La SERVICES, ON BEHALF OF THE WELD UN TM By: y C/( (1-4 Deput lerk to the Boar • Chair Signat ure AUG 2 9 2012 Protem Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Miller, Pamela OF HUMAN SERVICES 5151 W 29th Street, Unit 2004 Greeley, CO 80634 By: By c1-0-Alfact naWC.tIL!V 601) ;>, Director' Signatur Date Provider's Signature/Date By: Provider's Signature/Date 3 cQC/d 3%/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Miller, Pamela and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this , day of , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of th 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#1587465. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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. °9e Weld County Addendum to the CWS-7A � j/ 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 DI)One round trip a week O1%)2 round hips a week ❑2)3-4 round trips a week. ❑2'/:)5 round trips a week 03)6 round trips a week ❑3'/:)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? O Basic Maint.)No participation required O1)Once a month O1%)Two times month 02)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 of special education plan? ❑ Basic Maint.)No educational requirements DI)Less than a''/2 hour per day O1%)1/2 hour a day ►2) 1 hour a day 02 1/2) 1'/,-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? O Basic Maint.)No special involvement needed ] 1 1 Less than 5 hours per week O1%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedir bathing,grooming, physical,and/or occupational therapy? �] task Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) .01) Face-to-face contact one time per month with child and minimal crisis intervention. O1%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/z)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) {:)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/intensit of conditions which create the need for services that as 11 to this child. apa ' lid C y :"4. 'dap y ''. .y wa v� i 3 :qr+ xMy }� i .i ar, rai Pvx M,�' S '�1 1 F a t' die ,: +'ts„y $ �' t; i 3-' _ ty-c r yam. *' m :$ F d '+£ + • $ �asr r; `f n c ttlithr i °v �. i a_. . " 3 <�t.},..44 r:a.,.a.., „, :? *`' .v h' , i. v_;,° . ..fi e Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ 0 ❑ Verbal or Physical Threatening 0 0 0 El ❑ 0 0 Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ 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 El Enuresis/Encopresis ❑ ❑ ❑ ❑ 0 0 0 Runaway ❑ 0 0 0 0 ❑ ❑ Sexual Offenses ❑ ❑ 0 ❑ 0 0 0 6 Weld County Addendum to the CWS- • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. " I ' sit tie „" s istkr-te7Ixv4itc ' Ff_. lkt n - .a!iii 9 A.. ; ka 3'^ Inappropriate Sexual Behavior 0 ❑ 0 0 0 0 0 Disruptive Behavior ❑ ❑ 0 0 0 0 ❑ Delinquent Behavior ❑ ❑ 0 0 0 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition ist rated"severe", ❑ ❑ 0 ❑ ❑ 0 ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ 0 0 0 Eating Problems ❑ ❑ 0 0 0 0 0 Boundary Issues ❑ 0 0 ❑ 0 0 0 Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ 0 ❑ 0 ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1%z ❑ 2 ❑ 2'A ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE tt 3g Y{,cy .. ja x i Fps# ¢+�-,� l iA.� y'5 fi s '"s: �sh,�8� Sy� : . Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance Viu Rate Age 15-21...$19.27/day ($586/month) 00, Tt +Respite Care$.66/day ($20/month) tea. $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) 5"s $23.01 1 1/2 _ +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 + Respi te Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 :F '' +$.66 Respite Care Total Rate=($30.25 day/$920 month) ia< P-. $32.88 3 +$.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) 47, Assessment/Emergency t $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 S��> SERVICES, ON BEHALF OF THE WELD "A" N °4b��OUNTY DEPARTMENT OF HUMAN Mt. RVICES%61By: 1 �� /t/ . �i�_ . t% :1. tt� �t'Y: /./g1 `-7 Deputy.' erk to the Boar 4 Yy� hair Signature s.sProtem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Miller, Pamela OF HUMAN SERVICES 5151 W 29th Street, Unit 2004 Greeley, CO 80634 By: BY:. irnnQ � .,✓ i we f Couy t Direct r' ignat r /Date Provider's Signature/Date By: Provider's Signature/Date aVa- O7: 9 Weld County Addendum to the CWS-7A • UN/S-/A(KRI-IUPPI) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES • AND • FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7-a O--/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, Moore, Earl and Patricia, Provider ID#1517579, 135 Poplar St, Lochbuie, CO 80603, 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 GWS-/A(KIU-IU/9V) 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 UN/S-/A (KW-Ill/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 Bo. 1. % WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD v ` OUNTY DEPARTMENT OF HUMAN RVICES 1/42 By: l.�l/-/s j, '.� :1:. �!!y: Depu. lerk to the Boar Chair i proem ure AUG 2 9 2012 Approval as to Substance: r+i PROVIDER WELD COUNTY DEPARTMENT Moore, Earl and Patricia OF HUMAN SERVICES 135 Poplar St Lochbuie,`i. CO 80603 By: By: c e-zl80�2. -cT( 7—Q© /'_ Director's igna ure to Provider's Signature/Date �D a By. /P ovider s Signatuf&/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 Moore, Earl and Patricia and the 7017 AUG 21 A 9: 214 Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made this .2 I day of 2012, are added to the referenced Agreement. Except as modified hereby, all terms of t 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#1517579. 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. d/29- 3/i 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 01)One round trip a week ❑1'/:)2 round trips a week 02)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week 03%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 01)Once a month ❑1'/:)Two times month 02)Three times a month 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 01) Less than a '/:hour per day 01%) '/,hour a day ❑2) 1 hour a day 02 %) 1'h-2 hours per day 03)2'/z-3 hours per day ❑3%:)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.)No special involvement needed ❑l) Less than 5 hours per week ❑1'/)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) II 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 feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) I 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.) ❑I) Face-to-face contact one time per month with child and minimal crisis intervention. 011/2) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑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) DI) 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-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/mtensit of conditions which create the need for services that appl to this child. L.... :lea t a # io _ 4 o „ ,r. 33 °`fin`, .4""`' �' }s of ,' t a. o- ,. �y Q . pl�f�i i A i f ' a _. A e @'..'.{6 'r c n' 0 ,n fi R rigt t 1 rte u^. ig- >>ti k.;3 t x' 3' usq s 4' 9 i r .f A %.`'.54,...$, P�cfrg.e i. . x': i • a . a. .. ivs, F° ..iu.- _ ]'4 b.. . ...3. .. • ..4 Aggression/Cruelty to Animals 0 0 0 0 0 0 0 Verbal or Physical Threatening 0 ❑ ❑ 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 O O O Stealing ❑ 0 0 0 0 ❑ 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 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-7A S-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior BEHAVIOR of conditions which create the need for services that appl to this child ' '7..x d add.t ° 'l;n t.Gt +'fE) a' sr :W � 'd"v F i '., s a s .� i�#r.,. a�' s, �r at"3t. �r g a �tiy 's t t, . tys s4 QW 7 as s4 z .' s a_ °' 5. ; dAD*-P,P LOC,, 4 s �}y y „ c ,r ., , .� tea i:fi s s 3ak S F i 1y �x`� 4 iNt } yl s '� a�* a `" "" ,=•:„.-, �'�` .. Stat,. . . . i "'"""'1",":"...] 17 z,r li ✓r °sF i; .� _.. )'v fit:� ,,a;e ;j i- Inappropriate Sexual Behavior 0 0 0 0 0 0 O Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior O 0 0 0 0 0 ❑ Medical Needs (If condition is rated"severe", ❑ 0 ❑ 0 ❑ ❑ 0 please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ 0 0 0 ❑ 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 El CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) I-1 0 Ell ❑ 1'h ❑ 2 El 2'/z ❑ 3 El 31/2 7 Weld County Addendum to the CWS-7 (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 12 a p ax r # i• A r d "9`.,.-'``.441%.,.1\s'A; a„, sift �1 �E5,' c { titt'jr i 4 4 ' 'Fi t d +w 1;. { „, t 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) K $23.01 1 1/2 +$.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 4.66 Respite Care Total Rate=($40.11 day/$1220 month) AssessmentiEmergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7A • 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 4 °Q°a COUNTY DEPARTMENT OF HUMAN RVICES i t‘' 1/42 Depu lerk to the Boarjr�i ( i � � hair ignature protean AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Moore, Earl and Patricia OF HUMAN SERVICES 135 Poplar St Lochbuie, CO 80603 By: — By: Directo 's Sign t re/Dat Provider's Signature/Date By: ' ` Aire / �nv�*� Provider's Signature/Date 9 Weld County Addendum to ��// WA LWJ-/A(KIU-IU/YY) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, q- ,a I 'e)-- 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, Parker, Brian and Beryldell, Provider ID#1538709, 230 N 53rd Ave PI, Greeley, CO 80634, 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 07C'/07- 02,-571/ CWS-/A(KI U-IU/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 UNA/S-/A(K1U-Ill/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 Boar WELD COUNTY BOARD OF SOCIAL \ o,ILA) ERVICES, ON BEHALF OF THE WELD UNTY DEPARTMENT OF HUMAN kC? VICES 62t . Deputy perk to the Board ` � GGII hairS gna r AUG 2 9 2012 ,. ,..rProtem Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Parker, Brian and Beryldell OF HUMAN SERVICES 230 N 53rd Ave PI Greeley, CO 80634 By: - By: Direct ' Signature/ to Prod er's Signa re/DDate / By: /Gt<,� I�LG� 27,)f-fl Provider's Signature/Date 111 3 i)OA? 022// • WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Parker, Brian and Beryldell and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this)t( day of j i,t fitj , 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#1538709. 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. ,9C/02- 23 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 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? 0Basic Maint.) Less than one�round trip a week DI)One round trip a week 01%)2 round trips a week "'-'1 02)3-4 round trips a week. Cart S AaN5 ❑2'/z)5 round trips a week 03)6 round trips a week ❑3'/:)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? Basic Maint.)No participation required ❑1)Once a month O1%)Two times month 2)Three times a month 02.A)Once a week 03)Two times a week ❑3'/x)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? Qy Basic Maint.)No educational requirements ❑1)Less than a '/z hour per day O1.A) .72 hour a day 02) I hour a day 02 %) I'/z-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 DI)Less than 5 hours per week ❑1'/1)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 14 hours per week 0 3)Constant basis during awake hours ❑3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing,grooming, physical,and/or occupational therapy? la 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%) I I to 15 hours per week ❑3) 16 to 20 per week ❑3%)21 or more hours per week Comments: A I. How often is CPA/County case management required?(Does not include therapy) Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑l)Face-to-face contact one time per month with child and minimal crisis intervention. D11/2) 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%x) 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 1. How often are therapy services needed to address child's individual needs per NBC assessment? M0)Not needed or provided by another source(i.e. Medicaid) ❑l) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS- (Exhibit B) WELD COUNTY DNS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. Div �'"� �.e, 4313 d f , �., : �ro Ws as 'w m�5_ ate -,, I ` L! *1fa 4r--:.' ,g! 3+'ia''u Aggression/Cruelty to Animals -FL 0 0 ❑ ❑ 0 0 Verbal or Physical Threatening 4 ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting X ❑ 0 0 0 0 0 Stealing O ❑ 0 0 0 ❑ • Self-injurious Behavior X 0 0 0 0 0 0 Substance Abuse ❑ 0 ❑ ❑ 0 0 • Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 0 0 0 Enuresis/Encopresis O ❑ 0 0 0 ❑ Runaway X ❑ 0 ❑ ❑ ❑ ❑ Sexual Offenses / 6 Weld County Addendum to the CWS- S- (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/Intenslt of conditions which create the need for services that ar rl to this child z s,u''$'-w°14::"7"-:: ' �, ��, cs; � 3�3ra� ice+ + �`- r . a .�-5 @' Ail 4 : '..is k.. Yt Y 1 r m '• • r� � : :. 5 "In v ca � are :rs 14< ,x. 'I -e # . 5_ A sung c \t.',' ava Inappropriate Sexual / Behavior �](E` 0 ❑ ❑ ❑ O 0 Disruptive Behavior 0 0 ❑ ❑ ❑ 0 Delinquent Behavior / 5 ❑ 0 ❑ ❑ ❑ 0 Depressive-like Behavior qQ 0 0 0 0 0 0 Medical Needs / ' (If condition is rated"severe", f% 0 0 ❑ ❑ 0 0 please complete the Medically /-N,` fragile NBC) Emancipation ❑ ❑ 0 0 0 0 Eating Problems O 0 0 0 0 0 Boundary Issues ❑ 0 0 ❑ 0 0 Requires Night Care ❑ 0 0 ❑ ❑ ❑ H rvi dci rl O t hr� Education 5 ❑ ❑ ❑ ❑ 0 0 Involvement with Child's ' Family L[l� ❑ 0 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- (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE its s9 5� * : * -ii-L%p r'4441‘04,.1 b ) a P etd x a oYX �' s v.. tail �a �s Age 0-10...$16.32/day ($496/month) County Basic A.e 11-14...$18.05/da $549/month Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 r +$.66 Respite Care Total Rate= ($20.39 day/$620 month) ki- $23.01 1 1/2 +$.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) 1.44 $32.88 3 +$.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 -r: Effective 7/1/2008 8 Weld County Addendum to the CWS. IIV 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 th�.,;,e, ` WELD COUNTY BOARD OF SOCIAL S La SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN ' '� "vs .ERVICES By i / 1 !�!! ts!.!`�: ' By: Deput Clerk to the Boa e* rr✓ hair Signature Proem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Parker, Brian and Beryldell OF HUMAN SERVICES 230 N 53rd Ave PI Greeley, CO" 80634 ? �TGcI �/ By: . By: 43r.r.�, ,CSC 61-41 ty Directo s Signa re/Dat ovid s Signature/Date By: 7e--e-tic-e---- ( f Provider's Signature/Date 19/q'- Q3 9 Weld County Addendum to the CWS-7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, ,P/7 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, Pike,Wesley and Patricha, Provider ID#1611846, 719 Rodgers Circle, Platteville, CO 80651, 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 &94'- ?3// L W S-/A(K I U-J U/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 LWS-/A (ItIU-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 Boa : WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD � s,; COUNTY DEPARTMENT OF HUMAN ERVICES By: /flhLJt .. y Depu lerk to the Boa 7 Chair Signature ?totem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pike, Wesley and Patricha OF HUMAN SERVICES 719 Rodgers Circle Platteville, CO 80651 By: By: _ ��7-Z1-0 Director's ignatur ate Provider's Signatur`/1a� BY: 16V VD a Provider's SiSi ature/Date 3 &O/G- a2// WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Pike, Wesley and Patricha and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this 3& day of Ate , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of tement 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#1611846. 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 CWS-7A S� 3/� A 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 DI)One round trip a week ❑1'/:)2 round trips a week 02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week O 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 ❑l)Once a month ❑1%:)Two times month 02)Three times a month ❑2%)Once a week 03)Two times a week 03%)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 DI) Less than a '/,hour per day 011/2)1/2 hour a day ❑2) I hour a day ❑2 %) 1'h-2 hours per day 03)2''/-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed DI)Less than 5 hours per week ❑1%)5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedir bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 011/2)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week O 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.) ❑l)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1/)Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. O 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) ❑l)Less than 4 hours per month 02)4-8 hours per month 03)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/intensi of conditions which create the need for services that a..1 to this child. 10:22'AI%� i31b , 5. f!F i iana �,� r- .y f$i . , zee 61'A 4.. a Rio:.. .- I� it 4 ,.� I1/4„,1 '4'._,j l .i 4= �i 5 ,� ,.. f' �i i i t y a.. y.�i4 si. t i �i ,:.3 r ., ..,, ..', . _ �,... .m� Aggression/Cruelty to Animals ❑ ❑ 0 0 0 0 0 Verbal or Physical Threatening ❑ ❑ ❑ 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 ❑ ❑ Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ ❑ 0 ❑ 0 Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑ 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ 0 0 0 0 Runaway ❑ ❑ ❑ ❑ ❑ 0 ❑ Sexual Offenses ❑ 0 ❑ 0 0 ❑ ❑ 6 Weld County Addendum to the C W S-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that ar r I to this child. 3 c h G. s �i IMF 2!h,.}k 1 &� y s` ��$e, ^ 3 s ^rcS ._ 4yxF4.2.42;;212. r ea l4t 1.� .rY ear2':•;),54202;. r .3 „ r -v ar � lti a d -v :r ar '_� av Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 ❑ ❑ ❑ ❑ 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 ❑ ❑ ❑ 0 Medical Needs (It condition is rated"severe, ❑ ❑ 0 ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 ❑ 0 0 0 ❑ Eating Problems ❑ 0 0 ❑ ❑ ❑ 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ 0 ❑ ❑ ❑ ❑ ❑ Education ❑ 0 0 ❑ 0 ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1''/ ❑ 2 ❑ 2'/a ❑ 3 031/4 7 Weld County Addendum to the CWS-7 (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ihwe -ems ! d i s711151olomiiis,kthAhstiiiirettif VASA 0 e �l �`y s r E tvv ( !! _ fir Age 0-10...$16.32/day ($496/month) p�7v₹ County Basic - Ase 11-14...$18.05/da $549/month Maintenance Rate Age 15-21...$19.27/day ($586/month) Li> +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care is Total Rate= ($20.39 day/$620 month) +-'! $23.01 1 1/2 a +$.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 4.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$,66 Respite Care H :. Total Rate=($33.54day/$1020 month) $36.16 3 1/2 a=} +$.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 .Gs 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 WELD COUNTY BOARD OF SOCIAL \Se La SERVICES, ON BEHALF OF THE WELD .OUNTY DEPARTMENT OF HUMAN ' 1 ■ RVICES l{fit By: / / /� �. �� 91.'• \ ��Y: Deputy 'lerk to the Boar Chair Signature Prorem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pike, Wesley and Patricha OF HUMAN SERVICES 719 Rodgers Circle Platteville, CO 80651 By: By: i i ► � 741- Co n y Direct 's Signat a/Date ' ovider's Si:` e ate BY: 9YR in .SC, 7 O7I-Q Provider's Signature/Date aora R3%/ 9 Weld County Addendum to the CWS-7A LWS-/A tK 10-IV/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date; (3o l 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, Risner, Larry and Vivanco, Katherine, Provider ID#1552270, 1104 N 3rd St, Johnstown, CO 80534, 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 ?L(/a7- &3// L WS-/A (KIU-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 LWS-/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 Boar.0 sw WELD COUNTY BOARD OF SOCIAL Sad® �'e UNICES, ON BEHALF OF THE WELD TY DEPARTMENT OF HUMAN y VICES t.hF tt;2 By I .ii L.' ►�I / .�.I. Depu ler to the Board V , '� F Chair Signature AUG 2 9 2012 Protein Approval as to Substance: "' PROVIDER WELD COUNTY DEPARTMENT Risner, Larry and Vivanco, Katherine OF HUMAN SERVICES 1104 N 3rd St Johnstown, CO 80534 By: By: /7)1-N-A—ArligJI Director's igna re/ toP eider's Signature/Date B i _1,34z v �Provi er's Signature/Date 3 ao&- a3// • WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Risner, Larry and Vivanco, Katherine and the Weld County Department of Human Services for the period from July 1,2012 through June 30,2013. The following provisions, made this 2k) day of ,..)1 , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the greement 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#1552270. 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. &D/2 4 // 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 01)One round trip a week ❑1/)2 round trips a week ❑2)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week 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 DI)Once a month 011/2)Two times month ❑2)Three times a month 021/2)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 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 1/2) 1'h-2 hours per day 03)2'A-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 ❑1)Less than 5 hours per week 011/2)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2/) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the 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 02) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/:)21 or more hours per week Comments: _ A 1. How often is CPA/County case management required?(Does not include therapy) ['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1/)Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/:) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO)Not needed or provided by another source(i.e. Medicaid) ❑l) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS- (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/mtensits of condrttonsciai,i which create the need for services that apply to this child n t� 4Y.:2:¢1, IFI � t Pr. ' g�, 8t, �4i t - .. I .7, �k @ r �.:,{. ^''',C' '' i u ,fig Fg 't1 t. .a a .44.4„1/4.:-...7,7,4t,: _- k'a5 ry .,, Aggression/Cruelty to Animals ❑ ❑ 0 0 0 0 0 Verbal or Physical Threatening ❑ O ❑ 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing 0 0 0 0 0 0 0 Self-injurious Behavior 0 0 0 0 0 0 0 Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ 0 0 0 Sexual Offenses 0 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (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 apps to this child :-'::-.1:::::4010411111:— '� d , ��S::� F o� 1)( a r fkyy f `�+i . j tq.$1> . ,_ xy 7 "z ' t + i< 1 -s f'5 Sr : is # L t ii...k.:1;:;141.,,,"1.41."' :1 , '#�s` if,,., ti i. ti i ev5 y ,i, 7 d aax Yi'� ' .� a s s for eac'C . ' ' �, ' ' iii, t u a ... .a : i �$ �" 19k t '�,, Ua r # ''r a i�iRla ', .:�lk oafs. trot ky-=vt x9 Itl 7 kl3 k. `Ie r # '4@,k "+ at t ' ,7- ss4 #r iF nv' v Y "8i cL�v tl �[ , +� x gaa�t1 �,,,,, r./70% t '� ..l it ti PI . M '� Yf nt:a iM� i .K is H {I v� 101�h`#'� Inappropriate Sexual Behavior 0 ❑ 0 0 CI ❑ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ 0 0 El El ❑ ❑ Depressive-like Behavior ❑ ❑ 0 ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ ❑ ❑ 0 ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ 0 ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family CI CI CI ❑ CI CI CI CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 III 1 Az ❑ 2 ❑ 21/2 ❑ 3 ❑ 3'/ I 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 1,21,4iatsirratialiantailg,, `. i iR!'6-444hZ72:77 144111E til r E@ r a k r s= rsr a ¢3he't sr am t�a Arm L-S IPP at §spt ta-t ^b t is s,rLw11'su5 t 4: i t a* v,a a l ,nt sti K'' flia X53; 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) Tzlri $23.01 1 1/2 rrn, +$.66 Respite Care Total Rate=($23.67 day/$720 month) au, $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 21/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care NY 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) Ilif Assessment/Emergency Rate .' $30.25 day/$920 month(Includes Respite) Rate 'ii Effective 7/1/2008 8 Weld County Addendum to the CWS-7P ' J, IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the B'. . WELD COUNTY BOARD OF SOCIAL � S, SERVICES, ON BEHALF OF THE WELD .�' ® OUNTY DEPARTMENT OF HUMAN RVICES 1/42 Is61 e' By: �,:� l � , b$ :/i�{'i`•�a� ' adiy y: Deputy clerk to the Boas �y� air Signature AUG 2 9 proem 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Risner, Larry and Vivanco, Katherine OF HUMAN SERVICES 1104 N 3rd St Johnstown, CO 80534 1O 1 _ By: By: C/1 9 — u -1z C ty Dir c is Sig ure/D Provider's Signature/Date By: 30/ft ovider's Signature/Date 9 Weld County Addendum to the CWS-7A L W S-/A(K I U-I U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, TCL/A, /7 {r by and between the Board of Weld County Commissioners, sitting as the Board o' Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Ritter, Thomas and Deborah, Provider ID#1554009, 10151 Devonshire St, Firestone, CO 80504, 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 ar/a—a3// LWS-/A(KIU-IU/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 L W S-/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. nu AUG ee J��11 _8. To give at least two weeks notice of plans to remove a child from the facility. Thy tho ek 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 Boar.0 .,, WELD COUNTY BOARD OF SOCIAL s a°Pt SERVICES, LD OUNTY DEPARTMENT OF HUMAN44 Alt RVICES p 61 'Va.'? ( ,7_ Depu Cler to the Boar.' n' .�} Chair Signature / pi protem AUG 2 9 2012 Approval as to Substance: •" PROVIDER WELD COUNTY DEPARTMENT Ritter, Thomas and Deborah OF HUMAN SERVICES 10151 Devonshire St Firestone, CO 80504 BY By: Gek /�f CZ Direct ' Signature/ to rovider's Signature/Date Provider's Signature/Date 3 0212/91 022l/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Ritter, Thomas and Deborah and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this / ) day of ,,, , 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#1554009. 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. Q0ia-03, 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 01)One round trip a week 011/2)2 round trips a week 02)3-4 round trips a week. ❑2%:)5 round trips a week 03)6 round trips a week ❑3%) 7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required DI)Once a month ❑I'/)Two times month 02)Three times a month ❑2%x)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? O Basic Maint.)No educational requirements ❑l)Less than a ''/Y hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 'A) 1'/z-2 hours per day 03)2%z-3 hours per day ❑3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑11z)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 ase appropriate needs with feedim bathing,grooming, physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week DI'A)5 to 7 hours per week 02)8 to I0 hours per week 02%) I I to 15 hours per week ❑3) 16 to 20 per week 03'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.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. ❑I'A) 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. ❑2A)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%z)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) Di)Less than 4 hours per month 02)4-8 hours per month 03)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. P} 9+�`"'' IM �,. # .j 4 ,x a n ` err N .t h r:: 5r i :h .,�€ eia M ,,.x k c "k'�r,. '' kx. w k :1'1:•-114:',i4"'-'4"'' • ' �� ° 'i ld '4' 3"N OrA r ,4 G'ond� �t ngw� r''V A tb.l �ilif kht i .. `i h d # a #a i va 5s '' . x" t=rt T xn parfith r`r .. .� Moi-'" s y t s i'. r P i nl ( .c rk 16 r a e w .c° p7;1,i'c �� x : r iii s u r k a ai x r � jj yi Aggression/Cruelty to Animals 0 ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 ❑ Stealing ❑ 0 0 ❑ 0 0 0 Self-injurious Behavior ❑ ❑ 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 El 0 Presence of Psychiatric Symptoms/Conditions 0 0 ❑ 0 ❑ 0 0 Enuresis/Encopresis ❑ 0 0 0 ❑ 0 0 Runaway ❑ 0 El ❑ 0 ❑ 0 Sexual Offenses ❑ 0 0 0 El 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..Iy to this child 'r h Nn 'c'y x � ,-�h �� .i d rh y -Ti 7, tt a .5� 3.. $t''J'te'-')�i k "� :`^ u,..,, 1 r ; I of. ion. i hk aiiH �` aiee bn 15i N�. y'y i�rix,ng i_s .'a ".,'". r:*,,, ':-:. :' i + t . L F, >4 re '''f o-B'Lii d Eve MHIBinS tHIDgm P r R"Y$ ` yc Iii \a .l LL 4 J .`A nAiK `ii"r i i �1611�4c* Hr 1 iry i f(YiiPlitgVPF 7 It k ta: & ' 3 6 1.:� -kyos I .24:v .. . .. :• Si E�;� S t +i "iu.: Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 ❑ ❑ 0 ❑ Delinquent Behavior ❑ ❑ 0 ❑ 0 ❑ 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ 0 ❑ 0 0 ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ 0 0 0 ❑ Eating Problems ❑ 0 ❑ ❑ 0 ❑ ❑ Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care ❑ 0 ❑ 0 ❑ 0 0 Education ❑ 0 ❑ 0 0 0 0 Involvement with Child's Family ❑ 0 ❑ ❑ ❑ 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11 ❑ 2 ❑ TA ❑ 3 ❑ 3''/ 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE $ , � Ad a iA p`# i� tim " y s :i ygsA�. i 3 ..tea :'x a e ya x 'iliNaINITAISIL...1..‘`.,XttnirtiNIN.garThr K� a s 4 .u, a my M0 0:: a s a 4rs,m s '�e n `t�� }° 111 ��f ty� Age 0-10...$16.32/day ($496/month) County Basic ''s Age 11-14...$18.05/day ($549/month) Maintenance `.`_ Rate _ Age 15-21...$19.27/day ($586/month) +Respite Care$.66/da p' y ($20/month) $19.73 1 ;„: +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 a.s +$.66 Respite Care Total Rate=($23.67 day/$720 month) rtq $26.30 2 +$.66 Respite Care ck( 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) RIP $36.16 31/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 log TRCCF Drop Down -ti +$.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-i 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 t :,,� WELD COUNTY BOARD OF SOCIAL s SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN y � �„� SERVICES 1/42Aa\ ty By / ✓///a !��. . _..!�/v' r ti By: (N ( 1 Depu .�lerk to the Bo ti� rr.� hairi gtigiure '/Dram AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Ritter, Thomas and Deborah OF HUMAN SERVICES 10151 Devonshire St Firestone, CO 80504 By. By:7S----//4-1#9 -- my Dirac or's Sign re/Dat Provider's Signature/Date By: Qtyab 2-/4-(9 Provider's Signature/Date 072/c2-o2±t, 9 Weld County Addendum to the CWS-7A LWS-/H(KIU-IU/YY) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND • • FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, /4O.,<%tvi /i moo/ C by and between the Board of Weld County Commissioners, sitting as the Board of Soci/a1 Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Roderick, Douglas and Kelli, Provider ID#10994, 3110 57th Ave, Greeley CO 80634, 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 &C/c9 a8j/ C W S-/A(K I U-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 LW5-/A (KIU-111/99) 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 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 s.�/� WELD COUNTY BOARD OF SOCIAL �'`� `ERVICES, ON BEHALF OF THE�! WELD UNTY DEPARTMENT OF HUMAN VICES By: �/,/� Deput/lerk to the Board �' \ J Chair Signature 1 ' Proem AUG 2 9 2012 Approval as to Substance: """' PROVIDER WELD COUNTY DEPARTMENT Roderick, Douglas and Kelli OF HUMAN SERVICES 3110 57th Ave Greeley CO 80634 By By: � .�.. �"�!�J (� V ` I Directo s igna ure ate • 'vi.-r'• Sig ture/Date By: s gnature/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 Roderick, Douglas and Kelli and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this ILI day of 2012, are added to the referenced Agreement. Except as modified hereby, all terms oft Agreement remain unchanged. GENERAL PROVISIONS 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#10994. 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. 12C/c - 9i// 1 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 01)One round trip a week Dv/2)2 round trips a week ❑2)3-4 round trips a week. 02%) 5 round trips a week 03)6 round trips a week 03%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? O Basic Maint.)No participation required 01)Once a month 01%)Two times month 02)Three times a month ❑2%:)Once a week 03)Two times a week ❑3'/n)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 01%) 1/4 hour a day ❑2) 1 hour a day 02 /) I'/r2 hours per day 03)2'/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 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3)Constant basis during awake hours ❑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? O Basic Maint.)0-2 hours per week 01)3 to 4 hours per week ❑i'/)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 ❑39z)21 or more hours per week Comments: A I. How often is CPA/County case management required?(Does not include therapy) 0Basic 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. 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. 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? 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-i (Exhibit B) • WELD COUNTY DHS • NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. + r � '�� r r , +r J. qty ' � R '! tv. Sox; u t ,tig. , .: r s.. S�'* a R ;' a� c w 1. art � " r � Aggression/Cruelty to Animals 0 0 ❑ ❑ 0 ❑ 0 Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 ❑ ❑ ❑ ❑ 0 0 Stealing O 0 0 ❑ ❑ 0 0 Self-injurious Behavior O ❑ ❑ ❑ 0 0 0 Substance Abuse ❑ ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ 0 ❑ ❑ 0 0 ❑ Runaway ❑ ❑ ❑ ❑ 0 0 ❑ Sexual Offenses ❑ ❑ 0 0 ❑ 0 0 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 a..ly to this child t$ y s, s,„tall 142.44„,24-,&„ { ^)i `( '3" : rt r. ' 'a�>x i" •°J.: s vif: -e.t s ter tk 7 1 61P24.::::�v �i�� '�'� -{�,��' a;�q"�' . s ak�z. a 3 � } t� a i S t„ s�c. ,� d',�°''m �'� '� ', .��, � a w, {: x.^ 3Yk { I. ms 8 &. ¢air 'L g T. h t "T . ;.-ti 4 R fe` if Ct rc� � A _.f + _A : ��+ �;:!.1,4:::,47;' a � n�.. +tea . 'ate tia a sgit p f' �+ sx ' , �` w � msF t S'x 4 g ... .. _.,...4- n-rr"'�`'a ' s' > l e.... ,day,...;' _ -'$ a,. '^ ,t V ,,, s C � .c Inappropriate Sexual Behavior 0 0 0 0 0 0 O Disruptive Behavior ❑ 0 0 0 ❑ El 0 Delinquent Behavior ❑ ❑ ❑ 0 0 0 0 Depressive-like Behavior ❑ 0 ❑ El El ❑ ❑ Medical Needs (If condition is rated"severe", ❑ ❑ El ❑ 0 ❑ ❑ please complete the Medically fragile NBC) Emancipation El ❑ 0 El El ❑ El Eating Problems El El El ❑ 0 0 0 Boundary Issues ❑ 0 El ❑ ❑ El El Requires Night Care ❑ ❑ 0 0 0 0 ❑ Education El El ❑ ❑ El ❑ 0 Involvement with Child's Family ❑ ❑ El 0 ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 III 2% III ❑ 3''/ 7 Weld County Addendum to the CWS-7 • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE . f�'r+�� .fir .. Age 0-10...$16.32/day ($496/month) rr County Basic § Age 11-14...$18.05/day ($549/month) Maintenance ti Rate Age 15-21...$19.27/day ($586/month) ,7 �d€ +Respite Care$.66/day ($20/month) $19.73 1 11.4 • +$.66 Respite Care Total Rate= ($20.39 day/$620 month) titiT atai., $23.01 1 1/2 +$.66 Respite Care y• "• 1 Total Rate=($23.67 day/$720 month) t ,, t trait $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) M.}1. $29.59 2 1/2 +$_66 Respite Care �',,� Total Rate=($30.25 day/$920 month) P?" ff $32.88 3 • ;' +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 142.3 +$.66 Respite Care t^ri Total Rate=($36.82 day/$1,120 month) t $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) i^ ,... aa+ 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 B.. WELD COUNTY BOARD OF SOCIAL s La., ERVICES, ON BEHALF OF THE WELD UNTY DEPARTMENT OF HUMAN VICES ttal 1/42 By: ( / Deput ' lerk to the Board �' ' ( ;5� ♦ Chair SignatureAUG 2 9 2012 protem Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Roderick, Douglas and Kelli OF HUMAN SERVICES 3110 57th Ave Greeley CO 80634 By. By -t: . �L'_. - O1911 C my Dirk or's Sign t re/Dat P ivi. -r'satur•/Date By: / (/ `l(Z ro, • r ature/Date c9C/c 9 9 Weld County Addendum to the CWS-7A (KW-IV/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, P131/2 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, Serna, Leo and Carol, Provider ID#1597453, 1020 Cottonwood Dr, Windsor, CO 80550, 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. ') , _ ;iii L;“, 1 a047- psi/ U W J-/A(K I U-I U/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 LWS-/A(RIU-1U/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 Bo WELD WELD COUNTY BOARD OF SOCIAL fa SERVICES, ON BEHALF OF THE WELD La %COUNTY DEPARTMENT OF HUMAN ERVICES 4itftey ' /-O Deputy perk to the Bo �p �` Chair Signature ,.: Fromm AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Serna, Leo and Carol OF HUMAN SERVICES 1020 Cottonwood Dr Windsor, CO 80550 By: By: _ 7/3x99,2 irector ignature/ to Provider's ignat re/Date By: Q—UA —, I 7/30Pa Provider's Signature/Date 3 S®/a - aS/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Serna, Leo and Carol and the Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made this 3 day of Atsj-, 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#1597453. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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. aoi9-073// 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 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 ❑l)One round trip a week ❑1'/z)2 round trips a week ❑2)3-4 round trips a week. ❑2"z)5 round trips a week 03)6 round trips a week ❑3'/z)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑l)Once a month ❑1%)Two times month ❑2)Three times a month ❑2%z)Once a week 03)Two times a week ❑3'/z)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 ❑l)Less than a ''/z hour per day ❑1'%z) '%hour a day 02) 1 hour a day 02 %z) l''A-2 hours per day 03)2'/z-3 hours per day ❑3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the 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 01)3 to 4 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%z) 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 timeper 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. 011/2) 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) ❑l)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 DNS - NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. rR'j�' ��i4 35 ''+a. S r_ z :y >u &-s } L " ''-i l zxya ii i.i. Y,,i� *..z.,-....ta .,w :zi.a 9 11 �kk 3 • �q N. y..,.ry x ll4'%v ry i ° 4 li x.a ₹ x . ` xL i''� . Yom, 'C 3 '� f4 k{' M • 5 t MIAS a•4 xl 3x k'°!a a .''. y kr :i'x`t P:l§ ., . Y ta v a 5 ilf 3` F" P e re t_ s��.33** vs +ru ° r w� x 'a x -} t� a. aie r �w a+* s ., 3a k 4`:'.' ,. Aggression/Cruelty to Animals ❑ ❑ ❑ 0 0 ❑ 0 Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse O 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ 0 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 (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a•r I to this child. t a^ '' d S f 'wary otternnirsmithittini,,tcitime,411.„4;0f1Lr'Llir,4}K24, d i i '. 4SnSv �f I i 4 I.: �zI ' :.. r f+.,a,�t3' `fit�, : .. I c .�ttAapo'", r �� y4��' 3i inive ;.+ 4L 4!_ '. se ai ¢- - it: •t �m ,lx�. 5 gay�`�.t3v qrS ^,,} '".. — Inappropriate Sexual Behavior O O ❑ ❑ ❑ ❑ O Disruptive Behavior ❑ O O ❑ O O O Delinquent Behavior ❑ O O ❑ ❑ O ❑ Depressive-like Behavior ❑ O O ❑ O O O Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ O ❑ ❑ ❑ ❑ O Eating Problems ❑ O ❑ ❑ O O O Boundary Issues ❑ O ❑ O O ❑ O Requires Night Care ❑ O ❑ ❑ O O ❑ Education ❑ ❑ ❑ O ❑ O ❑ • Involvement with Child's Family O ❑ ❑ ❑ ❑ O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) 0 ❑1 ❑ 1% ❑ 2 El 2'/z ❑ 3 ❑ 3'/s 7 Weld County Addendum to the CWS (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ₹13.7Eqty 'F ' a ( 1"`7 fiV izn ryi✓r�1 d rrizaligir --. 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) 714. 44 $19.73 1 +$.66 Respite Care 44.72 Total Rate= ($20.39 day/$620 month) fti taw $23.01 11/2 +$.66 Respite Care *414 Total Rate=($23.67 day/$720 month) gig $26.30 2 +$.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) 441 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 ��"�►� SERVICES, ON BEHALF OF THE WELD \FeL OUNTY DEPARTMENT OF HUMAN RVICES Deputy 'erk lo the Boar Chair Chair Signature C r.. Prorem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Serna, Leo and Carol OF HUMAN SERVICES 1020 Cottonwood Dr Windsor, CO 80550 By: BY: L_ ? I 1 Z C ty Direct is Signatu /Date Provider's Signature/Date By 4 , K\Q 71 c I t Z Provider's Signature/Date c2C/d c5l-// 9 Weld County Addendum to the CWS-7A LW -/A (K LU-I U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT j 1. THIS CONTRACT AND AGREEMENT, made this date, /70' It by and bet vQep the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of "tic, the Weld County Department of Human Services, hereinafter called "County Department" and, Spahr, Mary Ellen, Provider ID#72929, 144 50th Ave, Greeley, CO 80634, 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 a�i�-a3i/ 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 LWS-/H(KIU-IU/99) 5. To give the provider a written procedure or authorization for obtaining medical care for the child. , 6r . 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 SERVICES, ON BEHALF OF THE WELD kda% OUNTY DEPARTMENT OF HUMAN RVICES Deput erk to the Boar w a . I Chair ' nature AUG 2 9 2012 Protein Approval as to Substance: � ,,,I PROVIDER WELD COUNTY DEPARTMENT Spahr, Mary Ellen OF HUMAN SERVICES 144 50th Ave Greeley, CO 80634 Q� / By: By: 412 q� Direct r' Signature/ a Prow e ' Sig ature/Date ! ✓ � /� By: Provider's Signature/Date 3 (5)O/a- o?3// WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Spahr, Mary Ellen and the Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made thisAd/' day of / i , 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#72929. 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. dC/a-ate// 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; q 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? 'rid trip a week ❑1)One round trip a week ❑1'/:)2 round trips a week 02%)5 round trips a week 03)6 round trips a week P 2. ider required to participate in child's therapy or counseling sessions? required 01)Once a month ❑1/)Two times month ❑2/)Once a week 03)Two times a week 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 m special education plan? 0 Basic Maint.)No educational requirements 01)Less than a ''/i hour per day 01%) 1/2 hour a day ❑2) 1 hour a day 02 %) 1'/z-2 hours per day 03)2%-3 hours per day ❑3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week ❑1'/:)5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedir 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/) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3''/)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. 011/2)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same 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) ❑1)Less than 4 hours per month 02)4-8 hours per month 03)9-12 hours per month 5 Weld County Addendum to the CWS. (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT q Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child: 4,, t"iaT Y €. ,.. • 9 p, r 4it, f 8 i i #ftitej t.l art. r. p4 �ry. s� 4s.. l ; V iv b}Na ". . ia, t .. - s-n, • ,„t 31..0�..a =# i= 7 ,<< a"•Aggression/Cruelty to Animals ❑ 0 0 0 0 0 0 Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 ❑ 0 Stealing O 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 ❑ 0 0 0 0 Substance Abuse O ❑ 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 Sexual Offenses 0 0 0 0 0 0 0 6 Weld County Addendum to the CWS (Exhibit B) WELD COUNTY OHS BEHAVIORNEEDS ASSESSMENTBASEDCARE CONTINUED Please rate the b of conditions which create the need for services that a..1 to this child. . S'�^'i.—`a"sa as Please r, t S r ,i behavior/intensity s rs ins i y k, i i * 1 a: t7 '' , �a'1.a.,Y' tar ti a* : ' y-N,£k § .V .� a 2s " • sv 4F rr e itia� #' 4 ,4;47,...44,44044714'4,1/44-04'41-1,--40:r'1-:4,44 L . 05 t 'ate'y*t�a, -- r '41-E ep£•.Fa` r '4 s1s . sA , 1 g`� "V rR.7�i` xf V n a �s ia,�,� a..,r�. c a �° V_r � ,� $ §•. k.:5;:--A„- ::.r3a mss. � - L� r s t. p ��a in s [. ^�;»i 5 �, x� ' ,2i RC,•vr V�" s • � � I� � SeV �� s E 4'4' L 1 Misr B k 5 1 v t s x s T, �1 Lt. : ° a ', 6 it t } fi �y 1 Inappropriate Sexual Behavior 0 0 ❑ ❑ ❑ 0 0 Disruptive Behavior ❑ ❑ ❑ 0 ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ 0 0 0 Depressive-like Behavior ❑ ❑ 0 ❑ ❑ 0 0 Medical Needs El ❑ ❑ ❑ ❑ ❑ ❑ (If condition is rated'sesere`, please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ ❑ 0 ❑ 0 0 0 Boundary Issues ❑ 0 ❑ 0 ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ 0 ❑ 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 El 11/4 ❑ 2 ❑ 2% Ill 3 ❑ 3'V2 7 Weld County Addendum to the CWS-'. • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE -a ?fie P 4441:2q.V4k2t 41-4.`' r I r,S t'-''`'. r Age 0-10...$16.32/day ($496/month) County Basic gc Age 11-14...$18.05/day ($549/month) Maintenance Mi Rate 31.4.1 vir Age 15-21...$19.27/day ($586/month) 414 41 52.4 +Respite Care$.66/day ($20/month) tali $19.73 1 ikt +$,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) WAI $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) a $29.59 2 1/2 • +$.66 Respite Care ,a: Total Rate=($30.25 day/$920 month) y'm! $32.88 3 +$.66 Respite Care el Total Rate=($33.54day/$1020 month) rta wiri $36.16 31/2 7.41 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) Al 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) ci 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 SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN slide SERVICES lt Deputy✓'erk to the Bo i « ' �J C2ature AUG 2 9 2012 Fromm Approval as to Substance: """'"� PROVIDER WELD COUNTY DEPARTMENT Spahr, Mary Ellen OF HUMAN SERVICES 144 50th Ave Greeley, CO 80634 BY: By: Zj//,/� C my Direct is Signa re/Date Prov s Signature/Date Y42 By: Provider's Signature/Date 9 Weld County Addendum to the CWS-7A LWJ-/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, 8 - o - a o/a 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, Van Den Elzen, Dawn, Provider ID#44282, 5819 W 16th St Ln, Greeley, CO 80634, 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 &O/c -a.3// UN/5.-/A(KIU-IU/YY) 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 (:WS-/A(KIU-IU/9`J) 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 ,•S SERVICES, ON BEHALF OF THE WELD Ir s La COUNTY DEPARTMENT OF HUMAN S%ERVICES • Deputy - lerk to the Boa ; ? 4'! Chai�tggnnature AUG 2 9 2012 PloApproval as to Substance: �. PROVIDER WELD COUNTY DEPARTMENT Van Den Elzen, Dawn OF HUMAN SERVICES 5819 W 16th St Ln Greeley, CO 80634 By: ' By: fon S _/ ©/2, Director' Signature/ to Provider's Signature/Date By: Provider's Signature/Date 3 c)-2O/c7- a3i/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Van Den Elzen, Dawn and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this / day of , 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#44282. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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. : c%?- 3/ 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 C WS-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 DNS 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 ❑l)One round trip a week ❑1'/z)2 round trips a week ❑2)3-4 round trips a week. 02%) 5 round trips a week 03)6 round trips a week ❑3%z) 7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month ❑1'/)Two times month 02)Three times a month ❑2%:)Once a week 03)Two times a week 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 of special education plan? ❑ Basic Maint.)No educational requirements ❑l)Less than a /z hourper day ❑1%z) '/:hour aday 02) I hour a day 02 '/s) 19z-2 hours per day ❑3)2'/z-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 ❑1)Less than 5 hours per week ❑1%z)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/z) I I to 14 hours per week ❑3)Constant basis during awake hours ❑3'/z)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 ❑I)3 to 4 hours per week ❑1%z)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑31/2)21 or more hours per week Comments: A I. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑l)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. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%z)Face-to-face contact three times per month with child and occasional crisis intervention. ❑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) ❑l)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/intensi q of conditions which create the need for services that a..l to this child. Y yr A4 rii �� ; F's'} FY f# S e'er C 'p^,' :j- , i a $ ,c; a u:' " i �+. 't '. 'i';'p. :� 'y4� a 4 4� 1 tYr• % tti a a t � � a # si x�'X #" . 'nom wr G .}�� y i• u"'i : : wv i 5 L I yy i i y�: a yy.9 ` l t*a ii ; i S a i # t :".4 1, .YS s 41 ik i ₹� � �.. y§ � . .:.. F :.' .5.., x .: ` f rn r�` 'a'a . �: � *4 •s � v p,�"'�..� �. Aggression/Cruelty to Animals 0 ❑ ❑ ❑ ❑ 0 ❑ Verbal or Physical Threatening 0 ❑ 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 ❑ Stealing ❑ 0 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 ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ 0 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-: • (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 a..1 to this child. x isu= i c , ry `sii s pia ri�� ` . s, : d 'af t & ate- 'r Ry. i 'r: t xf LAt its €I •e_ s .,ki i. kk is i kg {+ :k/w-c� ,� '1,44y4.O44r dr:13,541":"2:}x� r sa SS Y i e ,��..... ..:a - ,.a.:,.,,�t�,m V.1u,�.:.�.., `4`, , p'S<<- d .,...�'.. r—> =Y s 3 . F .,�„ is,w �`: Inappropriate Sexual Behavior ❑ 0 ❑ ❑ 0 0 0 Disruptive Behavior ❑ 0 0 ❑ 0 ❑ 0 Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ 0 Depressive-like Behavior ❑ 0 ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe', ❑ 0 0 ❑ ❑ 0 0 please complete the Medically fragile NBC) Emancipation ❑ 0 ❑ ❑ ❑ 0 ❑ Eating Problems ❑ ❑ ❑ ❑ 0 0 ❑ Boundary Issues ❑ ❑ ❑ ❑ 0 0 ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ 0 ❑ Education ❑ ❑ 0 0 0 0 ❑ Involvement with Child's Family ❑ ❑ 0 0 0 ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ I''/4 ❑ 2 ❑ 2''/ ❑ 3 ❑ 31/2 7 Weld County Addendum to the CWS- • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE mn `dm m i Y { .: _dry i } A•e 0-10...$16.32/da $496/month r�7 County Basic . Age 11-14...$18.05/day ($549/month) Maintenance 1'=' Rate '- , ;. Age 15-21...$19.27/day ($586/month) hit +Respite Care$.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/$720 month) h$,:14- $26.30 i<. 2 .1" +$.66 Respite Care ` Total Rate=($26.96 day/$820 month) lea�E $29.59 2 1/2 4.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care 7 Total Rate=($33.54day/$1020 month) $36.16 3 1/2 16a 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) in Assessment/Emergency Rate „fir. $30.25 day/$920 month(Includes Respite) Effective 7/1/2008 8 Weld County Addendum to the CWS- S- 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 COUNTY DEPARTMENT OF HUMAN Jj %`SERVICES tie By: / / .1 / i�h� +wu:y _ Deputy y erk to the B.. d air Signature ♦' proem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Van Den Elzen, Dawn OF HUMAN SERVICES 5819 W 16th St Ln Greeley, CO 80634 1' By: By: ,&e64M7 ,t1G¢, C u ty Direc or's Sign ure/Dat Provider's Signature/Date By: Provider's Signature/Date c9C/ -,g73// 9 Weld County Addendum to the CWS-7A CWS-/A (KIU-IU/VV) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, b /r7 /I2— 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, Vincent, Jessica and Ryan, Provider ID#1587461, 4910 W 2nd Street, Greeley, CO 80654, 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. S II a ••. :i— -id Li.. 1 (9oia 23// LWS-/A (KfU-IU/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-/A(KIU-111/99) 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 B. ` WELD COUNTY BOARD OF SOCIAL "5,001/40; SI La SERVICES, ON BEHALF OF THE COUNTY DEPARTMENT OF HUMAN WELD SERVICES • By: 4.n Deputyperk to the B,t air Signature !� Piofe AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Vincent, Jessica and Ryan OF HUMAN SERVICES 4910 W 2nd Street Greeley, CO 80654 By By: c/i/Iz Direc r ignatur ate Provider's ignature/Date By: o/ 7 /IZ ro der's Signature/Date 3 0204-�3// WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Vincent,Jessica and Ryan 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 day of 54-, 2012, are added to the referenced Agreement. Except as modified hereby, all terms of t 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#1587461. 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. c2Z'/a-a3/I 1 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 he 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 Do One round trip a week ❑1%z)2 round trips a week O2)3-4 round trips a week. ❑2'/x)5 round trips a week O3)6 round trips a week ❑3%z) 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 ❑I)Once a month ❑1'/z)Two times month O2)Three times a month O2%)Once a week O3)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 ❑I) Less than a''/z hour per day ❑1'%) '/z hour a day ❑2) 1 hour a day ❑2 '/z) 1'/z-2 hours per day O3)2'%-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 Do Less than 5 hours per week ❑1'/a)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'/z) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3'/z)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'/z)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑I) 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. O2)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. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/z) 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) ❑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 7 (Exhibit B) WELD COUNTY OHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..I to this child. e I s � �., ki 'mss#_ e ��-�. �,� r i i S i t I a ;� c a "C‘., )�{ae :� a l'I a MErt iit' � a bu::''.1....1,9- L. tiv ali: t a + t ', k .' gyogy 4 b � S0.� -`au - �.: EJ Yom- m: Aggression/Cruelty to Animals 0 0 0 ❑ 0 0 ❑ Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 ❑ ❑ ❑ ❑ ❑ 0 Stealing ❑ 0 ❑ ❑ ❑ 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 ❑ Substance Abuse ❑ 0 ❑ ❑ ❑ ❑ 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ 0 0 Enuresis/Encopresis ❑ 0 ❑ 0 ❑ 0 0 Runaway ❑ ❑ ❑ ❑ 0 0 ❑ Sexual Offenses ❑ 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/intensit of conditions which create the need for services that a..1 to this child. ,-. ..Ra ,t l¢ � 'kiff h ,...,?.....;:,,z- atA it t , ;if,. 0 t r + ��e�r...,,, x �r fa"F€ tr;,ate'� � . . igs` � �' a ', a aa ` c .e ,�. { a :1; nom h:- i" 1". ';;', Y�.'. .. q `3 t o.e �.., 4 �Y.K �r Fa ". +i slit -,t....vl ?-' \J.il _ 1,: -, if, ?..tiltu ii.,N q;,'+ ' fl &}p y test gpitisi,03,;;F:rf„;Inappropriate Sexual Behavior ❑ 0 0 0 ❑ ❑ 0 Disruptive Behavior ❑ 0 0 0 ❑ 0 0 Delinquent Behavior ❑ 0 ❑ ❑ 0 0 ❑ Depressive-like Behavior ❑ 0 0 ❑ 0 ❑ 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ 0 El 0 ❑ ❑ 0 Eating Problems ❑ 0 0 ❑ ❑ ❑ 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ El ❑ Requires Night Care ❑ ❑ ❑ 0 ❑ 0 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% ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'/ 7 Weld County Addendum to the CWS= (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE a7,7, i ;':;1•TF 4 i t y Alf 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) $19.73 +$.66 Respite Care tit Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 ode." +$_66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 112 +$.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 t, $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS- A 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 �r S OUNTY DEPARTMENT OF HUMAN 1 VICES By: Deput lerk to the Boar.\' f�� , Chair Signature `r•a;,�,,.� Protein AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Vincent, Jessica and Ryan OF HUMAN SERVICES 4910 W 2nd Street Greeley, CO 80654 • By: J1JJO _ By: ty Dirept 's Signa e/Date rovider's Signature/Date By: Or g/7 / 1Z Provider's Signature/Date (Z3/j 9 Weld County Addendum to the CWS-7A CWJ-/H 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, L\\a T1?OIL by and between the Board of Weld County Commissioners, sitting as the Board Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Wade, Michael and Jodyne, Provider ID#1554152, 1016 Cottonwood Dr,Windsor, CO 80550, 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 LW ,-/A(K I U-I U/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 LWS-/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 SERVICES, ON BEHALF OF THE WELD t[G a UNTY DEPARTMENT OF HUMAN VICES •?a By: &( [G Deputy erk to the Board `� /Chair Signature AUG 2 9 2012 rioter? Approval as to Substance: ROVIDER WELD COUNTY DEPARTMENT Wade, Michael and Jodyne OF HUMAN SERVICES 1016 Cottonwood Dr Windsor, CO 80550 By: -7) <� Director's ignature/ to ro r' Signature/Da Provide Signature/Date 3 ao/c9- ,Z3// WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Wade, Michael and Jodyne 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.`Z day of s•N ' , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of th greement 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#1554152. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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. 4I 6wo B. Be submitted by the 4th of ea$lii�Snth'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. aO/0?- 73/ I 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' 7, 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 ❑l)One round trip a week ❑1%)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? ❑ Basic Maint.)No participation required ❑1)Once a month 01%)Two times month ❑2)Three times a month ❑2'/z)Once a week 03)Two times a week 03%)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 ❑l)Less than a '/,hour per day 011/2) 1/2 hour a day 02) I hour a day 02 %) 1'h-2 hours per day 03)2'/:-3 hours per day ❑3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed DI)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week 0 3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feedin bathing,grooming,physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%)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. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same 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 CWS- (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions whies_ch create the need for services that a.el to this child. ittc.Olan4r:tetaeit**/-11;-*tg _ITtrargikis teratrts+._,21'h%ritISPII-!'1';.4:A*4.ieiiiiitg":44tritKilvi4ktr*:;:ctert.'24: -;0.1„ 4 .=":.i k s_, k p!t• `•_H v€.' a o a . -it{� �vSS q gg r :. ¢I,:IT. 'k 44. 11 1 1 ;el*!.".:.:.y..5.--- t .... .'. ,: es,...,: wEE ow-wt. is - Ifs '. .. E re .. _ �� q:. { s.0 E ?p'4v{,d�. .. rt�.. Aggression/Cruelty to Animals ❑ ❑ ❑ O O O O Verbal or Physical Threatening ❑ O ❑ ❑ ❑ O O Destructive of Property/Fire Setting O O ❑ O ❑ O O Stealing ❑ O O O O ❑ O Self-injurious Behavior ❑ O O O O O O Substance Abuse ❑ O O ❑ O ❑ ❑ Presence of Psychiatric Symptoms/Conditions O ❑ O O O O ❑ Enuresis/Encopresis ❑ O ❑ O O O O Runaway ❑ O O O O O ❑ Sexual Offenses ❑ ❑ O O O O O 6 Weld County Addendum to the C W S- • (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 a..1 to this child. i`k,. '1`4.117 m !, .:. " ' F *��'° ?�` ":: � - y t s r.� 44:7Ii ' °'"*t •(si4w . te':-.' a, sit �,Fe 'a.' , u` m ..in�'.ncR "' e� rtn k a�₹.Sa.. �a „. F x na4 rwa t�?� yy r "t4 :_ 9 .5x•. �° .. S: s ",.d"' e."4 r .4,e , h xrs'f5.�' r`t x{x *h t .� r t: �w •r'fit ':Hi' � �' k a e �r b is s spa 'Via,t+a^c, t ,. :, x ',..,',.c...... :y ..`^N a `t Mtry sotiktottil kcsiCejtaaltalkisSelk 1,...s.•:,Saggilz k,a�g � ;zf, Stka S ti 0.7),:11::::tt !<,,:,,,,,:1-3,....,....4i.1.. Inappropriate Sexual Behavior ❑ O ❑ O O ❑ O Disruptive Behavior ❑ ❑ ❑ O ❑ O ❑ Delinquent Behavior ❑ O O ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ O ❑ O O O O Medical Needs (If condition is rated"severe', ❑ El ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ El ❑ ❑ ❑ El O Eating Problems ❑ O ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ El El El El El Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ O ❑ O ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ O ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/4 ❑ 2 ❑ 21 ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS• (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE /k"' �w R:. a,m a z ,x . 3, s eat`:. { ryxy -17oacturbsvaief. 4.3',110''':0 t6 t. eta �6� y Age 0-10...$16.32/day ($496/month) County Basic A.e 11-14...$18.05/da $549/month Maintenance Rate WI A.e 15-21...$19.27/da $586/month) +Respite Care$.66/day ($20/month) $19.73 4 +$.66 Respite Care r Al 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) $36.16 31/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) rm4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) tJ � f1lyi"t jts S ZY ? f R'f't a �...,.�� et3+�,.atc �lso.,a lab Assessment/Emergency R `_ Rate ,;;w,_ $30.25 day/$920 month(Includes Respite) Effective 7/1/2008 8 Weld County Addendum to the CW5 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 COUNTY DEPARTMENT OF HUMAN ERVICES . 1— Depu lerk to the Bo.'%T"�� ' Chair Signature Protem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Wade, Michael and Jodyne OF HUMAN SERVICES 1016 Cottonwood Dr Windsor, CO 80550 1 By: BY U_.1 'c 125 {2, C u ty Direct is Sign4 ure/Dat ro er's Signature/Date By: 7/25/R Provide s Signature/Date 9 Weld County Addendum to the CWS-7A LW -/A (K 1U-11)/99) U-1 U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, Af n.T / ,a%0),,.,2 by and between the Board of Weld County Commissioners, sitting as the Board7of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Walker, Kurt and Jennifer, Provider ID#1546248, 519 Trout Creek Ct,Windsor, CO 80550- 3194, 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 62Cia- a3ij I:WJ-/A(KIU-IU/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 LWS-/A(KIU-IU/99) 5. To give the provider a written procedure or authorization for obtaining medical care for the child. ' 8. ' 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: � , SERVICES, ON BEHALF OF THE ARD OF WELD r aAL COUNTY DEPARTMENT OF HUMAN .,SERVICES <` 412 7♦� By: `�i /LA s �� '/i!•� �,By://f/ ` .� Deput flerk to the Bo vv ,> Chair Signature AUG 2 9 2012 ?totem Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Walker, Kurt and Jennifer OF HUMAN SERVICES 519 Trout Creek Ct Windsor, CO 80550-3194 By: By: V wILL Directo s Signatur / ate Providder'ss((SSi�ignature/Date By: ovideklsSign�aturre/Date 3 &o/a- 6937/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Walker, Kurt and Jennifer and the Weld County Department of Human Services for the period from July 1,2012 through June 30,2013. The following provisions, made this / day of 2012, are added to the referenced Agreement. Except as modified hereby, all terms of t 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#1546248. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 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, 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 01)One round trip a week ❑1%z)2 round trips a week ❑2) 3-4 round trips a week. ❑2%:)5 round trips a week ❑3)6 round trips a week ❑3%z) 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 01%)Two times month 02)Three times a month ❑2'/z)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 O0 Less than a '/z hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 %z) 1'/:-2 hours per day ❑3)2'/2-3 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 ❑1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%z) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3%z)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%) 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) 0 Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/z) 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) DI)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-i • (Exhibit B) WELD COUNTY OHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate die behavior intensit of conditions which create the need for services that a..I to this child. .i-?.—a i• .Thik '?..,''.7,-, e't =1•,,9 i r : X: iy4 ,/ } r..77f b rrs C l� • e , 1 r t a I. s F y 4 .; A rS "."`€'' 1,_ s: is ��.,, ir' l+ ; h __/.-,-,--7,7-7-4,1.1-:‘,.- �rir tis t it y F ti ty tea` c1 $� N +,"f, / s ).4.9, & 407-:(I ? u .gal . �" _ ',• • [ a }13a f :*-)51 ih s�s' �a" &, ,6s�5 a r Ali,ty�'ft. ' E' T d .. aitWit • F . _ *; .,cx,.- _ .. ;wv�,a_ Nom " ` Aggression/Cruelty to Animals 0 0 0 0 0 0 0 Verbal or Physical Threatening 0 0 0 ❑ 0 0 0 Destructive of Property/Fire Setting 0 0 ❑ El El 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 ❑ 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CW S ' (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. �sr ik w41- I" b r t rAncliaNgeoif.at.4.wk.;p,,-a ._ t ty* v +� Y ax's .- A t s i i 1 1 tl a c • �9t • :Atcs,.I tr*t � ' ra pri' s }I ' R b t 1 Sx:A ^'s ', . ' ,x T ' - f` r' lis $ ,+ $r i C,ia t• .r i :, 4. fs°ks'Lisd,,," it .uL „°r r r yi4% �s7F44't-a E" �443k .. ,-44 y a: ;& s` E£ca, ' ., ;."O,.° tiri f2.:','$. -i %4 4„ -1-.'" T 4; l 3 ai Y. 5 $" iV fri, e'r.: t x .? . tM , m kr.V 0tt q Inappropriate Sexual Behavior ❑ ❑ 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior O 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 ❑ Medical Needs (If condition is rated"severe', ❑ El 0 0 ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation O 0 0 0 ❑ 0 0 Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care O 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1i4 ❑ 2 ❑ 2% ❑ 3 ❑ 31/2 7 Weld County Addendum to the CWS-i t • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ¢ ra E�.� �3~ .pv yat 6 x �. +C !$T ly st d Y 2 Age 0-10...$16 32/day ($496/month) County Basic "« :P Age 11-14...$18.05/day ($549/month) Maintenance Rate 72L Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) 4s t+, $19.73 7 i +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care -'.4:1 Total Rate=($23.67 day/$720 month) 11, $26.30 2 w; +$.66 Respite Care Total Rate=($26.96 day/$820 month) +.'�. . $29.59 2 1/2 �Ke 4.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3r.��-. +$.66 Respite Care l Total Rate=($33.54day/$1020 month) 11 $36.16 3 1/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) t9. $39.45 TRCCF Drop Down ° +$.66 Respite Care Total Rate=($40 11 day/$1220 month) "i�it fi ?xrc' Assessment/Emergency .±.:0,4 $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 _ SERVICES, ON BEHALF OF THE WELD J� ®`� SERVICES DEPARTMENT OF HUMAN SE By LIB j114'4 By: Deputy ' erk to the��4 �? 'Y 1 Chat Signature ' ?totem AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Walker, Kurt and Jennifer OF HUMAN SERVICES 519 Trout Creek Ct Windsor, CO 80550-3194 By: By: Q ty Dir t is Signa e/Date P ovt Signature/Date By. �P tde ignature/Date c9D/. d3, 9 Weld County Addendum to the CWS-7A UWS-/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, B d /�� ,v7by and between the Board of Weld County Commissioners, sitting as the oar of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Wyatt, Justin and Tracy, Provider ID#1601806,418 Dogwood Ct., Eaton, CO 80615, 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 �®/,2-(23// LWS-/A(KIU-11P99) 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 I:WS-/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 Bo s WELD COUNTY BOARD OF SOCIAL fol SERVICES, ON BEHALF OF THE WELD ` COUNTY DEPARTMENT OF HUMAN %SERVICES -Th 41/42 By. y Depu !Clerk to the Bo�'" �' Chair Signature p �� em AUG92012 Pro Approval as to Substance: "" PROVIDER WELD COUNTY DEPARTMENT Wyatt, Justin and Tracy OF HUMAN SERVICES 418 Dogwood Ct. Eaton, CO 80615 By: By' I2— 'rector's S nature/Da r ider's Signature/Date 811; 301 12 Provid is i natur / ate 3 c)O/c2-c2S// WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the"Agreement") between Wyatt,Justin and Tracy 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 day of %I� c�T, 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#1601806. 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, • 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' �, 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 01)One round trip a week DI'/z)2 round trips a week ❑2)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week ❑3'/z)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 01)Once a month ❑1'/z)Two times month 02)Three times a month ❑2'/z)Once a week 03)Two times a week ❑3'/z)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 01) Less than a%hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %z) l''A-2 hours per day 03)2'%-3 hours per day ❑3Yz) 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 O1) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑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 feedit bathing,grooming, physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/z)5 to 7 hours per week 02) 8 to 10 hours per week ❑2'/z) I 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'/z)Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T I. 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) ❑I)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 a..l to this child. ,a ^, H: .aa a x :W7 sva SSA' j c. e t ';''...11 asses *I -"T;",;;;',4!;;;,..1-,...`+ . a tr rn -. A s ' '.« s 12�. 'i4 „, s t t t y r ,x e ',,,t,,,,,',,,,„.."' r ir f:t ili�,,,Fa 1F r— r k a "„ti ,§ r .,• e r ''' d Vii° '` ,av, t�w a "' # In ';P: ' . c r ,,,,,r,:' w a 74.241:2 d1! i, .; rrii tr ina q - ',h d 4 ts'� °r: `-}'t n vie ,„ ..., .� � .. .Gdd�,§�,tf1„�nx-Lne. v"G 3.Ktf5rl�a:a3. n asStkau�W a .i e� :d+i?:..»m`b.: a_ �.ai�x"a'edi�er.'dw�'eYs Aggression/Cruelty to Animals ❑ ❑ 0 ❑ 0 0 0 Verbal or Physical Threatening ❑ ❑ ❑ 0 0 ❑ El Destructive of Property/Fire Setting 0 0 0 ❑ 0 0 0 Stealing ❑ ❑ ❑ 0 0 ❑ 0 Self-injurious Behavior ❑ 0 El 0 0 0 ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ 0 0 Runaway ❑ ❑ ❑ 0 0 El ❑ Sexual Offenses ❑ ❑ 0 0 0 ❑ 0 6 Weld County Addendum to the CWS (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. 3 s, t { 9 a ; � F '42 h � �v ' fie yitj. :d... e. l I d s d . ' d " d — ... p . x �t it , d s.>:`� i $$kda. SSA' • u i Inappropriate Sexual Behavior 0 0 ❑ ❑ 0 CI Disruptive Behavior 0 0 ❑ ❑ ❑ ❑ 0 Delinquent Behavior ❑ 0 0 ❑ 0 ❑ El Depressive-like Behavior 0 0 0 ❑ ❑ 0 El Medical Needs (If condition is rated"severe", El El ❑ ❑ ❑ El El please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ El ❑ Eating Problems ❑ El ❑ ❑ ❑ 0 El Boundary Issues ❑ ❑ El ❑ El El ❑ Requires Night Care El ❑ El ❑ ❑ ❑ ❑ Education ❑ ❑ El ❑ El ❑ ❑ Involvement with Child's Family CI CI ❑ ❑ CI El CI CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'/2 ❑ 3 n___ 3'/2 7 Weld County Addendum to the C W E (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Int 471:1arsy y �, ''rr�� 4 ry 6r� yr :".i"'�xF `Se §...-�„ i' 1 Age 0-10...$16.32/day {$496/month) County Basic 44 Aqe 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) x:i' k +Respite Care$.66/da p y ($20/month) =r( $19.73 1 +$,66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 ii 1 112 +$.66 Respite Care 441 Res Total Rate+$ ($23.67 day/$720 month) $26.30 2111 +$.66 Respite Care Total Rate=($26.96 day!$820 month) $29.59 • 2 1/2 +$,66 p Care Total Rate=($30.25 day/$920ite month) 3 +$,66 Respi88te Care Total Rate=($33.54da$32y/$1020 month) askti $36.16 3 1/2 +$.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) 41 Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rate Noo Effective 7/1/2008 8 Weld County Addendum to the CWS-7i J . 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 EsL ,COUNTY DEPARTMENT OF HUMAN ® RVICES By. Deputy ' erk'to the Boar. r' air Signature Protein AUG 2 9 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Wyatt, Justin and Tracy OF HUMAN SERVICES 418 Dogwood Ct. Eaton, CO 80615 By: Byc oJintY Direct is Signa e/Date ro er's Signature/ ate Provide ' •gna e/Date 9 Weld County Addendum to the CWS-7A Hello