HomeMy WebLinkAbout20122088.tiff RESOLUTION
RE: APPROVE STANDARD FORMS FOR AGREEMENT TO PURCHASE OUT-OF-HOME
PLACEMENT SERVICES AND ADDENDUMS THERETO BETWEEN THE WELD COUNTY
DEPARTMENT OF HUMAN SERVICES AND VARIOUS PROVIDERS,AND AUTHORIZE
CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with forms of an Agreement to Purchase
Out-of-Home Placement Services and Addendums thereto, between the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Human Services, and various providers, with further terms and conditions being as
stated in said forms, and
WHEREAS, after review, the Board deems it advisable to approve said forms, copies of
which are attached hereto and incorporated herein by reference, and to delegate standing authority
to the Chair of the Board of County Commissioners to execute individual agreements and
addendums between the Department of Human Services and various providers.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, ex-officio Board of Social Services,that the forms of the Agreement to Purchase
Out-of-Home Placement Services and Addendums thereto, between the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Human Services and various providers be, and hereby are, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said agreements and addendums between the Department of Human Services and various
providers upon presentation.
2012-2088
« . tAS HR0083
RE: APPROVE STANDARD FORMS FOR AGREEMENT TO PURCHASE OUT-OF-HOME
PLACEMENT SERVICES AND ADDENDUMS THERETO BETWEEN THE WELD COUNTY
DEPARTMENT OF HUMAN SERVICES AND VARIOUS PROVIDERS
PAGE 2
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 8th day of August, A.D., 2012.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST „
Seen P. C Chair11
Weld County Clerk to the Board _ �J
Will m . Garci , Pro-Tem
BY:
Deputy Cler to th Board j EXCUSED
arbara Kirkmeyer
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APP AS O XCUSED
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unty Attorneyifi C�' ,}�( odCpwtq.�.kt�
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Date of signature: 3 ;.3-/
2012-2088
HR0083
auE
1861
MEMORANDUM
DATE: July 27, 2012
N T Y TO: Sean P. Conway, Chair, Board of County Com ' sioners
G Q_U — o (. L J
FR: Judy A. Griego, Director, Human Servi es Depa men
RE: Weld County Addendums and List of Out-of-Home
Providers to be Submitted to the Board of County
Commissioners
Attached, please find the proposed Weld County Addendums and list of out-of-home providers
for SFY 2012-2013. These Addendums remain the same from last year and will be submitted to
the Board of County Commissioners for their consent agenda. These Addendums were reviewed
under the Board's Pass-Around Memorandum dated June 13, 2012, and approved for placement
on the Board's Agenda.
Directory:
Attachment I (Page 3) —Agreement to Purchase Out-of-Home Placement Services SS23A.
This is the State prescribed agreement that was revised in February 2012 which is used for all
out-of-home care except county foster care homes. Per Colorado Department of Human
Services, Volume 7, this agreement cannot be altered.
Attachment II (Page 12)—Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement.
This agreement is the State prescribed agreement used for county foster care homes. Per
Colorado Department of Human Services, Volume 7, this agreement cannot be altered.
Attachment III (Page 16)—2012-2013 RCCF Addendum and provider list.
Rates are based on the state standard rates established for the contract year 2012-2013 (also
known as base anchor rates). No COLA is being recommended for the 2012-2013 fiscal year.
Attachment IV (Page 22) —2012-2013 County Certified Foster Care Addendum and
provider list.
Rates are based the Needs Based Care Assessment and rate table as approved by the Board of
Weld County Commissioners. No COLA is being recommended for the 2012-2013 fiscal year.
Attachment V (Page 33) —2012-2013 Child Placement Agency addendum and provider list.
Rates are based on the Needs Based Care Assessment and rate table as approved by the Board of
Weld County Commissioners. No COLA is being recommended for the 2012-2013 fiscal year.
Attachment VI (Page 42)—2012-2013 Group Home/Center addendum and provider list.
Rates are negotiated per home/center due to highly specialized care for children who are stepping
down from RCCF care or cannot maintain in a foster care home setting.
O7v/o2-,7a 88
Attachment VII (Page 47) —2012-2013 RCCF/CHRP Addendum and provider list.
Rates are based on a negotiated rate per agency due to highly specialized care for children who
are not eligible or who are awaiting approval for CHRP.
Attachment VIII (Page 52)—2012-2013 Specialized Group Home Addendum and provider
list.
Rates are based on the approved rate structure as outlined in DHS policy/procedures manual
section 2.308.5. No COLA is being recommended for the 2012-2013 fiscal year.
Attachment IX (Page 57)—2012-2013 Out of State RCCF Addendum and provider list.
Rates are negotiated based on the high level of needs the child requires. These providers are out-
of-state providers who provide residential care for Weld County children that have exhausted all
Colorado resources.
If you have any questions, please give me a call at extension 6510.
Attachment I
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
CHILD PLACEMENT AGENCY SERVICES (CPA)
❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP)
❑ GROUP HOME/GROUP CENTER CARE
❑ INDEPENDENT LIVING
❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF)
❑ RESIDENTIAL CHILD CARE FACILITY (RCCF)
❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM
❑ SHELTER CARE
❑ SUBSIDIZED ADOPTION
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER (DESCRIBE):
THIS IS AN AGREEMENT, made this day of between the Weld County
Department of Social/Human Services hereinafter called "County" and «CPA_NAME»,
«MAILING_ADDRESS», «CITY_STATE_ZIP», hereinafter called "Contractor."
THIS AGREEMENT:
Shall include all children placed by the Weld County Department of Social/Human Services and placed
with «CPA_NAME».
A child specific addendum, identifying individual service needs, must be completed and attached to
supplement this agreement for each child being served by the facility. If this is a CPA placement, the
child specific addendum should also address how administrative services will be provided in the event
the child is placed for adoption in a foster home supervised by the CPA.
WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department"
is authorized to provide social services to individuals and families of individuals through its agents,
County Departments of Social/Human Services, and
WHEREAS, the County is authorized to purchase certain services for eligible children under State
Department rules, and
WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and,
WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility,
certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service
types.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County
and the Contractor agree as follows:
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1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the
end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the
facility prior to the end of the fiscal year by the county department.
2. This Agreement may be renewed only by entering into a new written Agreement such as
this Agreement signed by the authorized representatives of the parties. Except as
otherwise provided above, either party shall have the right to terminate this contract by
giving the other party thirty (30) days notice by registered mail, return receipt requested.
If notice is so given, this contract shall terminate on the expiration of the thirty (30) days
or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the
liability of the parties hereunder for further performance of the terms of this Agreement
shall thereupon cease, but the parties shall not be released from the duty to perform their
obligations up to the date of termination.
3. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED:
1. The total rate of payment for care and services under this Agreement shall not exceed: the established
rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF
placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate;
and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care
and services for other service types will be as negotiated between the County and the Contractor.
Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs.
The amount paid for purchased care and services for less than a full month will be based upon the daily
rate.
2. Payment for a child's temporary absence from the facility, including absence due to hospitalization,
will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12
CCR 2509-5).
3. Transportation shall be furnished by County between the child's residence and Contractor's facility
for the initial placement and return after the treatment plan is completed. If the child runs away from the
Contractor's facility, the County shall provide transportation to either return the child to the facility or to
other care as arranged by the County. The County has responsibility for the decision to return the child
to the facility, with input from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be provided by
Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be
negotiated between County and Contractor and are not subject to reimbursement under this Agreement.
However, provisions for payment of other transportation may be provided for in the Family Service Plan
/ Individual Plan of Care.
5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by
persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service
plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan.
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SECTION II: LEGAL STATUS AND AUTHORIZATIONS:
1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or
emergency medical and dental treatment except that:
a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of
Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services,
eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any
items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall
govern activities to be covered in the daily rate paid to PRTFs.
2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening,
Diagnosis and Treatment Program.
3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and
social activities of Contractor, including supervised off grounds excursions and extended trips within the
State, provided that Contractor has written permission from County and legal guardian for any trips out
of Colorado for any reason and any planned absence from the facility of over seven (7) days within a
consecutive 30-day period. Such written permission may be in the treatment/service plan. Further,
Contractor and County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a
PRTF is not Medicaid reimbursable.
4. County and Contractor shall inform each other and the local school district of any changes in parental
residence affecting educational status which comes to their attention.
SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS:
1. County and Contractor agree and understand that the reasons for referral, which necessitate
purchasing services for children are specified in the attached child specific addendum and Family
Services Plan. Any other relevant information concerning these children that does not necessitate
purchasing services is also included in the addendum.
2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency
needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF.
County and Contractor shall formulate an initial individual plan of care within 14 calendar days after
admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in
the attached child specific addendum included with this contract. The Child's Family Service Plan may
be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be
agreed to in writing on the plan or as a supplemental document.
3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within
72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the
multidisciplinary team within 14 calendar days from the placement date. The placement date is that date
noted in the attached child specific addendum included with this contract. Modifications to this plan
shall be agreed to in writing on the plan or as a supplemental document.
4. The individual plan of care shall be goal oriented and time-limited and shall:
a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and
other needs including the child's presenting problems, physical health, emotional status,
behavior, support system in the community, available resources, and discharge plan.
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b. Include specific goals and measurable objectives, expected dates of achievement, specific
discharge and transitional/after-care and follow up services criteria to be met for termination of
treatment.
c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services,
medication management, emergency services, initial assessment, documented treatment
modifications, and other services determined to be necessary to meet the child's specific goals.
d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat
the child's current diagnosis.
e. Identify the provision of, or the referral for, services other than RCCF services and shall
document any court ordered treatment including identifying the agency responsible for providing
the court ordered treatment.
f. Anticipated living arrangement for the child at the date of discharge;
g. Anticipated educational arrangement for the child at the time of discharge;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall
conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have
been achieved or not achieved. These parties shall provide the County with written reports which
address changes to the child's physical condition, psychological and social functioning, changes in the
child's family situation, educational progress, significant incidents or disciplinary actions, and progress
made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports
to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews
when provided with 30 calendar days advance notice of such dates by County.
6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the
child's physical condition, psychological and social functioning, changes in the child's family situation,
educational progress, significant incidents or disciplinary actions, and progress made to achieve goals
specified in the treatment plan.
SECTION IV: CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services,
the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado
and any applicable federal laws and regulations, as such, which may be amended from time to time, and
shall be binding on Contractor and control any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State law and rule.
3. Not charge any fees to children or families of children referred by county for any services provided
under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express
written approval of the Director of the County Department or his/her appointed designee.
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5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964,
Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised,
and provide confidentiality of information concerning the child in compliance with the Health Insurance
Portability and Accountability Act (HIPAA).
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs
and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage
to any one person, and $600,000 for total injuries arising from any one accident.
7. Maintain during the terms of this Agreement a fidelity bond of at least$25,000 or two (2) months
gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees
responsible for the implementation and/or administration of this contract in order to make reparations for
any wrongful acts, omissions, or any other defalcations of the Contractor.
8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care
Policy & Financing, and the State of Colorado against any and loss against all claims and actions based
upon or arising out of damage or injury, including death, to persons or property caused or sustained in
connection with the performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or actions.
Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments.
9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own
wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing
their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in
this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act
set forth in §24-10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the
University of Colorado, its employees or agents under this Agreement.
10. Maintain service program records, fiscal records, documentation and other records, which will
sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of
this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by
federal, Colorado Department of Human Services, Colorado Department of Health Care Policy &
Financing, or county personnel, and other persons authorized in writing by the Executive Director of the
Colorado Department of Human Services.
11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home
study, the SAFE study update, annual certification updates and related materials when requested by the
County within fourteen working days of the request. At all other times the Contractor shall make home
studies and related materials available to the County for review, at a location agreed upon by the County
and the Contractor, during regular business hours.
12. Bill the County for services rendered, using the required form. This form is to be mailed to the
County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System
only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the
County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County
only. Contractor will not be paid by the county when billing is not received by the County within 30
calendar days following the billing due date.
13. Attend and participate in Administrative Reviews for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over
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the age of twelve to attend their Administrative Reviews. Participation may be in person or by
teleconference.
14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child
maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or
room and board amount shall be treated as income to the foster parent.
SECTION V: COUNTY SHALL:
1. Determine eligibility of the children under this Agreement for placement and medical coverage.
Medicaid rules and regulations shall govern determination of Medicaid eligibility.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of
Human Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time
frames for services purchased under this Agreement in accordance with the established rate when billing
is submitted as described in Section IV, Number 10 (above).
4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules
and regulations and the laws of the State of Colorado, any of which may be amended from time to time.
5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing
allowance in accordance with State Department rules.
6. Monitor children's progress in accordance with the treatment/family services plan and the
requirements of Colorado Department of Human Services rules and provide consultation to Contractor in
relation to the services purchased under this Agreement.
7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review.
8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services
Plan at time of placement or as soon as completed and when updated or revised.
9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid
payment amounts that have been misused as defined in rules. The County may withhold subsequent
payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall
seek recovery of any remaining funds as a debt due the County for the benefit of the state. The RCCF or
CPA may appeal the decision to recover or withhold subsequent payments as defined in rules.
10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent
for the child's room and board. Such amount will be the same as shown in Trails for the child's
maintenance.
11. Reimbursement rates that are negotiated between the County and the Contractor shall be for
allowable costs in one or more of four primary components: child maintenance, administrative services,
administrative maintenance, and treatment. Contractor type will determine which of these four
components will be included in the reimbursement rate.
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SECTION VI: GENERAL PROVISIONS:
1. The Parties to this Agreement intend that the relationship between them, contemplated by this
Agreement is that of employer independent contractor. No agent, employee, or servant of Contractor
shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and
entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the
performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of Colorado,
county, and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect
personal items brought to Contractor by the children, Contractor will be released from responsibility for
loss or damage to such personal items.
4. This Agreement is intended to be applied in conjunction with the child specific addendum and family
services plan as the complete integration of all understandings between the parties. No prior or
contemporaneous addition, deletion or other amendment hereto shall have any force or affect
whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or
other amendment hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as either prohibiting the periodic amending of the family
services plan or appending a county designed addendum to this agreement.
5. The contract shall permit the State Department to monitor service program, fiscal and other records
sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the
aforementioned client. Monitoring may occur through review of program reports, on-site visits where
applicable and other contracts as deemed necessary. The Contractor understands that the State
Department may provide consultation to Contractor to assure satisfactory performance in the provision
of purchased services under this Agreement.
A. All reimbursement requests shall be submitted to and approved by the appropriate County
staff Reimbursement for placement services shall be paid from the date of admission up to, but
not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP
placements are permitted on the day of discharge in compliance with regulations promulgated by
the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed
as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this
contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and
CHRP services paid by the Department of Health Care Policy and Financing. Payment for
placement services will not be provided for clients on "runaway" status unless the County has
previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF,
RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with
instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings
to the County on a monthly basis.
In the event that a Contractor receives payment for a per diem discharge day, regardless of
funding source, the Contractor shall refund those dollars forthwith.
B. The purpose of these requirements is to provide minimum assurance that the Contractor has
adequate accounting and budgeting information available to allow management to maintain a
financially viable enterprise and to demonstrate financial accountability to the county
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departments of human/social services and Colorado Department of Human Services for the use
of public funds.
(1) The Contractor must have in place a double entry accounting system and all financial
transactions must be posted to this system. Financial statements, prepared from information
provided by this system, shall be presented in conformity with U.S. generally accepted
accounting principles (GAAP). The Contractor must also have adequate time keeping and cost
allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and
records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying
by appropriate Federal, State or county personnel, or such independent auditors or accountants as
may be designated by these personnel.
(2) All billing by the contractor must be in a format approved by the fiscal agent or county.
Contractors must bill the fiscal agent and county at least once a month. Contractors may bill
twice a month, on the 15th and last day of the month, for services rendered. Bills will be
returned unpaid if the bills do not conform to the approved format or the documentation is
inadequate.
(3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual
audit of their financial statements by an independent certified public accountant. Contractors
with total annual expenditures less than $100,000 may submit an audit as described above or
may submit compiled or reviewed financial statements, prepared in accordance with generally
accepted accounting principles. If the Contractor is a government agency that has an independent
audit done by another agency of that government, its audited financial statements, prepared in
accordance with generally accepted accounting principles for state and local governments meet
this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and
CPAs must be completed and a copy provided to the Colorado Department of Human Services
(Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs)
within 180 days after the contractor's fiscal year end. The audited financial statements and
supplementary information defined in regulation for various agencies shall be presented as
described in Section VI, B (1), above and must contain sufficient detail to provide evidence of
financial accountability under the terms of this contract and controlling state regulations.
Contractors that are a subsidiary of a parent organization must submit separate financial
statements for the subsidiary that detail each of the Contractor's facilities and/or programs that
provide services for the Colorado Department of Human Services and also must provide a
reconciliation of these financial statements to the consolidated financial statements of the
organization as a whole. When applicable, the Contractor must comply with the audit
requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of
1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States,
Local Governments, and Non-Profit Organizations including subsequent revisions, and
appropriate audit and financial reporting requirements as defined in State laws, rules, and
regulations.
(4) If Contractors do not submit their annual audit or refuse to disclose financial information
regarding the operation of the program in a timely manner, the Fiscal Agent may withhold
payment until the audit and/or requested information is submitted. If the contractor is a CPA,
then sanctions of the contractor may occur for failure to submit.
(5) In cases where documentation does not exist to support audit information or services
provided, contractor will be required to repay all funds received for which documentation does
not exist.
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(6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to
the State Department's Audit Division for approval within 4 months of the date of the audit.
(7) Failure to comply with any of these requirements, including items on the addendum is
justification for the County to impose fiscal sanctions, penalties, or cancel the contract.
6. In the event this contract is terminated, final payment to the Contractor may be withheld at the
discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error,
fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent
payments under this contract or other contracts between the County and the Contractor or by the County,
as a debt due to both the State of Colorado, the Colorado Department of Human Services and the
County. The waiver of any violation shall not be construed as a waiver of any other or subsequent
violation of this contract or appropriate statutes and regulations.
WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first
written above.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By: By:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «CPA_NAME»
OF HUMAN SERVICES «MAILING ADDRESS»
«CITY_STATE_ZIP»
By: By:
County Director's (or designee's) Director's (or designee's) Signature
Signature and Date and Date
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Attachment II
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, «NAME», Provider ID#«PROVIDER_ID», «MAILING_ADDRESS»,
«CITY STATE ZIP», 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.
12
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the
child for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as recorded
in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons
in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
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.
13
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative
visitation plans, and other specific characteristics of the child, with the provider before
placement and to share additional information when obtained.
2, To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
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.
14
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By: By:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT «NAME»
OF HUMAN SERVICES «MAILING ADDRESS»
«CITY STATE ZIP»
By: By:
Director's Signature/Date Provider's Signature/Date
By:
Provider's Signature/Date
15
Attachment III
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Residential Child Care Facility Services (the
"Agreement") between «RCCF NAME» and 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.
County agrees to purchase and Contractor, identified as Provider ID#«FACILITY_ID»,
agrees to provide:
A. Child Maintenance, Administrative Maintenance and Services, which are listed in this
Agreement at a rate of$«RCCF_RATE» per day for children placed within the
Residential Child Care Facility.
B. Additional services not covered by Medicaid or considered within the above vendor rate.
These additional services/rates may be negotiated on a child by child basis, based on the
needs of the child and in accordance with the Colorado Department of Human Services
Agency Letter CW-06-11-I dated June 8, 2006.
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.
2. Section I, Paragraph 1. County considers the agreed upon rate, outlined in the Weld County
Addendum to this contract, to be all inclusive and shall not pay for additional treatment fees; i.e.
Drug/Alcohol and Sex Offender services
3. Section I, Paragraph 2. 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. Reimbursement rates for bed hold days may not exceed the
state standard rate for administrative maintenance and administrative services or may be a
reduced rate that is mutually agreed upon.
4. Section 1, Paragraph 4. Transportation may include, but is not limited to; visitation with family
members, medical/dental or mental health appointments, extracurricular activities, court hearings
or other specialized programming. Transportation expectations will be documented on the Child
Specific Addendum, SS23B.
5. Add Paragraph 6 to Section I. The services purchased under this Agreement as Child
Maintenance, Administrative Maintenance and Services for Residential Child Care Facilities
include, but are not limited to: Food, shelter, clothing, personal needs and allowance,
administration, administrative overhead, support staff, support overhead, sleep-over staff, direct
child care, transportation, therapeutic recreation, service delivery staff, parent training for teens,
independent living training, mentor/advocate, supervised visitation and all other services as
outlined in the Child Specific Addendum. The anticipated minimum percentage for each item is
as follows and will be subject to County monitoring as outlined in Section VI of this contract:
A. Food, including meals and snacks (25%);
B. Clothing (3%);
16
C. Shelter, including utilities and use of household furnishing and equipment and daily
supervision, including those activities that a parent would normally carry out to assure
protection, emotional support and care of the child (30%);
D. Personal items and grooming care for the child, such as toothpaste, toothbrushes, soap,
combs, haircuts, and other essentials (2%);
E. Other/miscellaneous items considered usual in the care and supervision of the child,
include, but are not limited to, transportation, recreation and overhead (40%)
6. Add Paragraph 7 to Section I. A minimum of one polygraph test per Colorado fiscal year, if
needed by the child, will be furnished by the Contractor under this contract for facilities that
provide sex offender treatment.
7. Add Paragraph 8 to Section I. Any additional costs for specialized services, which include, but
are not limited to; polygraph tests, plethysmographs, and urinalysis screens, that is not provided
within the vendor rate or attached Scope of Service, will need be negotiated and authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency
medical, surgical or dental care will be made in person-to-person communication, not through
phone mail messages. During regular work hours, the Contractor will make every effort to
notify the assigned caseworker, supervisor, or intake screener of any emergency medical,
surgical or dental issues prior to granting authorization. During non-regular work hours,
weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager
number (970) 304-2749.
9. Section III. Paragraph 5. Contractor additionally agrees to have appropriate personnel available
for staffing current placements with the Service Utilization Unit. Provider shall be notified by
County staff of the date and time of the review.
10. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County Department
of Human Services to shorten the duration of placement.
11. Add Paragraph 16 to Section IV. Have physical examinations completed within 14 days and
dental examinations completed within 8 weeks of the child being placed with Contractor. All
documentation of these examinations shall be forward to the County.
12. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student every 3 years and coordinate reviews
every year. If the IEP is due while the child is in placement, the Contractor will complete or
obtain a completed IEP. A copy will then be forwarded to the County.
13. Add Paragraph 18 to Section IV. 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; violation of federal or state
17
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.
14. Section V, Paragraph 5. Children in Residential Child Care Facilities and Child Placement
Agencies are not eligible to receive clothing allowances as outlined in the Weld County
Department of Human Services Policy and Procedure Manual.
15. Add Paragraph 7 to Section VI. 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.
16. Add Paragraph 8 to Section VI. 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.
17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the
following remedial actions should s/he find the Contractor substantially failed to satisfy the
scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be
defined to mean incorrect or improper activities or inaction by the Contractor. These remedial
actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which have
not been performed and which due to circumstances caused by the Contractor cannot be
performed or if performed would be of no value to the Human Services. Denial of the
amount of payment shall be reasonably related to the amount of work or deliverables lost
to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement or other agreements between Human Services and the Contractor, or by
Human Services as a debt to Human Services or otherwise as provided by law.
18. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the
event in which it is a party defendant or respondent in a case, which involves services provided
under the agreement. The Contractor, within five (5) calendar days after being served with a
summons, complaint, or other pleading which has been filed in any federal or state court or
18
administrative agency, shall deliver copies of such document(s) to the Human Services' Director.
The term "litigation" includes an assignment for the benefit of creditors, and filings in
bankruptcy, reorganizations and/or foreclosure.
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
SERVICES
By: By:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «RCCF_NAME»
OF HUMAN SERVICES «MAILING_ADDRESS»
«CITY_STATE ZIP»
By: By:
County Director's Signature/Date Contractor's Signature/Date
19
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Attachment IV
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
«NAME»
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
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#«PROVIDER_ID». 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.
22
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'
23
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;
24
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)
25
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.) Less than one round trip a week 91) One round trip a week ❑('/)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'/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?
O Basic Maint.)No participation required ❑1)Once a month ❑1%)Two times month
02)Three times a month ❑2%z)Once a week ❑3)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 o
special education plan?
❑ Basic Maint.)No educational requirements ❑1) Less than a '/z hour per day ❑1%) '/z hour a day
❑2) 1 hour a day ❑2%z) I'/-2 hours per day ❑3)2'/-3 hours per day
❑3%)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed 01) Less than 5 hours per week ❑1'/:)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'/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 feedii
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 I. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1/) Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%) Face-to-face contact three times per month with child and occasional crisis intervention.
93)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
26
(Exhibit B)
WELD COUNTY DNS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions
(Check one box for each category)
r
Assessment Areas Mild/ Moderate! High/ Comments: :..
None Mild Moderate. ` Moderate Fl eh Mieh Severe';
0 1 1 1/2 2 2 1/2 3 3 1/2
Aggression/Cruelty to
Animals ❑ ❑ ❑ 0 ❑ ❑ 0
Verbal or Physical
Threatening ❑ ❑ ❑ ❑ 0 ❑ ❑
Destructive of
Property/Fire Setting ❑ ❑ ❑ ❑ IT ❑ ❑
Stealing
❑ ❑ 0 ❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ 0 ❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑ ❑ ❑ 0
Sexual Offenses
❑ ❑ ❑ ❑ 0 ❑ ❑
27
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions'* -
(Check one box for each category)
Assessment Areas Mild/ Moderate Hit/ Comments:
None Mild Moderate. Moderate ' /High Limit - Severe
0 1
1 1/2 2 21/2 3 - 3 1/2
Inappropriate Sexual 0
❑ ❑ ❑ ❑ ❑ ❑
Behavior
Disruptive Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ 0 ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ 0 ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated ❑ ❑ ❑ ❑ ❑ ❑ ❑
"severe", please complete
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ 0 ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ 0 0 ❑
Boundary Issues
❑ ❑ ❑ ❑ 0 ❑ ❑
Requires Night Care
❑ 0 0 0 ❑ ❑ 0
Education
❑ ❑ ❑ 0 ❑ 0 ❑
Involvement with Child's El ❑ ❑ 0
❑ 0
❑
Family
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑l ❑ 1'/: ❑ 2 ❑ 2'1/ 0 3 ❑ 3'/z
28
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
RECOMMENDED
LEVEL OF SERVICE PROVIDER RATE
P1 -PS'.
Level Rate --
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate Age 15-21...$19.27/day ($586/month)
+ Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +5.66 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)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
29
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
SERVICES
By: By:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT «RCCF_NAME»
OF HUMAN SERVICES «MAILING ADDRESS»
«CITY_STATE_ZIP»
By: By:
County Director's Signature/Date Provider's Signature/Date
By:
Provider's Signature/Date
30
Foster Care Service Providers
2012-2013
PROVIDER
NAME - ID MAILING ADDRESS CITY STATE ZIP
1 Almond, Earl and Cindy 61603 1000 Country Acres Dr. Johnstown, CO 80531
2 Baker, Elissa 1552821 1224 Westwood Dr Windsor, CO 80550
3 Caldwell, Matthew and Marjorie 1610333 1605 84th Ave Greeley, CO 80634
4 Carter, Jeremy and Susan 1556173 1204 Tanglewood Windsor, CO 80550
5 Castillo, Arturo and Elsa 1592544 905 Greenwood Ct. Fort Lupton, CO 80621
6 Charter, Denise 1610286 3903 Falcon Lane Evans, CO 80620
7 Corliss, Wade and Loni 1547483 26649 CR 60 1/2 Greeley, CO 80631
8 Crowder,Jeffrey and Elaine 1611538 316 Amber Drive Windsor, CO 80550
9 Drury, Dean and Karla 1606578 1301 38th Ave Greeley, CO 80634
10 Eddy, Daniel and Marta 1531353 4737 S. Urban Way Morrison, CO 80465
11 Erbacher, Dan and Hallie 1546381 3850 Cheyenne Dr Greeley, CO 80634
12 Fisher, Matthew and Claire 1532312 5022 W 2nd St Rd Greeley, CO 80634
13 Foster, Denise 1551571 10656 Bald Eagle Circle Firestone, CO 80504
14 Fritz, Nancy 1539167 3925 Stampede Dr. Evans, CO 80620
15 Froggatte, Samuel and Rachelle 1601426 213 N 52nd Ave Greeley, CO 50634
16 Gomez, Oswald and Christina 1588508 7226 Matheson Dr. Fort Collins, CO 80525
17 Gutierrez, Elisa and Hoffer, Christopher 1519595 10101 W 13th St Rd Greeley, CO 80634
18 Heimer, Sara 1547292 3000 W 19th St Greeley, CO 80634
19 Hernandez, Roberto and Margarita 1520297 912 Elm Ct Fort Lupton, CO 80621
20 Hoeft, Kimberly 1603004 5551 W 29th Street, Unit 712 Greeley, CO 80634
21 Jude, Yvonne 1585656 2406 14th Ave Greeley, CO 80631
22 Kinney, Frederick and Margaret 1547583 640 E 3rd St Eaton, CO 80615
Thornton, CO 80241-
23 Kniss, Kevin and Kelly 1524303 13089 Marion Dr. 1936
24 Maronek, Dennis and Patricia 1520627 4860 Eagle Crest Blvd Firestone, CO 80504
25 Mauk, James and Harriett 1537621 3620 Dilley Circle Johnstown, CO 80534
26 McGee, Donna 1539853 1649 31st Ave Greeley, CO 80634
27 Means, Nathan and Lisa 1601788 2632 15th Ave Greeley, CO 80631
28 Mena, David and Marie 1510691 2905 41st Ave Greeley, CO 80634
5151 W 29th Street, Unit
29 Miller, Pamela 1587465 2004 Greeley, CO 80634
30 Moore, Earl and Patricia 1517579 135 Poplar St Lochbuie, CO 80603
31 Parker, Brian and Beryldell 1538709 230 N 53rd Ave PI Greeley, CO 80634
32 Pike, Wesley and Patricha 1611846 719 Rodgers Circle Platteville, CO 80651
33 Pluma, Mike and Annette 35126 PO Box 34 Kersey, CO 80644
34 Redding, Christopher and Sonja 1524128 2305 42nd Ave Greeley, CO 80634
35 Risner, Larry and Vivanco, Katherine 1552270 1104 N 3rd St Johnstown, CO 80534
36 Ritter, Thomas and Deborah 1554009 10151 Devonshire St Firestone, CO 80504
37 Roderick, Douglas and Kelli 10994 3110 57th Ave Greeley CO 80634
38 Serna, Leo and Carol 1597453 1020 Cottonwood Dr Windsor, CO 80550
39 Shindle, Danny and Andrea 1550177 1561 41st Ave Ct Greeley, CO 80634-2758
40 Spahr, Mary Ellen 72929 144 50th Ave Greeley, CO 80634
41 Steele, Dana and Cassandra 1551234 324 Fossil Dr. Johnstown, CO 80534
42 Steitz, Daniel and Natalie 1546930 1701 Elder Ave Greeley, CO 80631
31
PROVIDER
NAME ID MAILING ADDRESS CITY STATE ZIP
43 Van Den Elzen, Dawn 44282 5819 W 16th St Ln Greeley, CO 80634
44 Vincent, Jessica and Ryan 1587461 4910 W 2nd Street Greeley, CO 80654
45 Wade, Michael and Jodyne 1554152 1016 Cottonwood Dr Windsor, CO 80550
46 Walker, Dylan and Jessica 1611851 1841 Green Wing Drive Johnstown, CO 80534
Windsor, CO 80550-
47 Walker, Kurt and Jennifer 1546248 519 Trout Creek Ct 3194
48 Willert, Melody D and Lee, Kimberly 1540372 219 N 4th St LaSalle, CO 80645
49 Wyatt, Justin and Tracy 1601806 418 Dogwood Ct. Eaton, CO 80615
32
Attachment V
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between «CPA_NAME» and 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.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the CPA identified as Provider ID#«FACILITY_ID». 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. County and Contractor agree that for Children's Habilitation Residential Program
(CHRP) waiver eligible children, the County agrees to pay the federal SSI rate to
Contractor and all other service costs will be billable under the CHRP program.
4. Section I, Paragraph 2. 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.
5. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
6. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
7. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
33
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
9. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Contractor
shall be notified by County staff of the date and time of the review.
10. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County
Department of Social Services to shorten the duration of placement.
11. Add Paragraph 16 to Section IV. Have physical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
Contractor. All documentation of these examinations shall be forward to the County.
12. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized
Educational Plan (IEP) for youth designated as a Special Education Student every 3 years
and coordinate reviews every year. If the IEP is due while the child is in placement, the
Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to
the County.
13. Add Paragraph 18 to Section IV. 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;
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.
14. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Residential Child Care Facilities and Child Placement Agencies are not eligible to receive
clothing allowances as outlined in the Weld County Department of Social Services Policy
and Procedure Manual.
15. Add Paragraph 7 to Section VI. 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
34
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
16. Add Paragraph 8 to Section VI. 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.
17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
18. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
19. Add Section VII- EXHIBITS:
35
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID's/ SEX RAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HII# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
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'/1)2 round trips a week
❑2) 3-4 round trips a week. ❑2%) 5 round trips a week ❑3)6 round trips a week
❑3%) 7 round trips or more
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 91%) Two times month
O2)Three times a month 92%)Once a week 93)Two times a week
❑3'/) Three times a week or more
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 t
special education plan?
❑ Basic Maint.)No educational requirements ❑1) Less than a '/z hour per day ❑1'/z) '/z hour a day
❑2) 1 hour a day 92 %) 1'/-2 hours per day 93)2'/-3 hours per day
❑3%) More that 3 hours per day
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 ❑1'/n) 5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑ 3)Constant basis during awake hours ❑3'/)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond aee appropriate needs with feedi
bathing, grooming, physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%) 5 to 7 hours per week
92) 8 to 10 hours per week 92%) 11 to 15 hours per week ❑3) 16 to 20 per week
93%)21 or more hours per week
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.)
91)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.
❑2%)Face-to-face contact three times per month with child and occasional crisis intervention.
❑3) Face-to-face contact weekly with child and occasional crisis intervention.
❑3'/:) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T I. How often are therapy services needed to address child's individual needs per NBC assessment?
90)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
36
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions
(Check one box for each category)
Assessment Areas Mild/ Moderate/ High/ Comments:
None Mild Moderate. Moderate High Hid Severe
0 1 11/2 " 2 21/2 3 31/2
Aggression/Cruelty to
Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑
Verbal or Physical
Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑
Destructive of
Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑ ❑ ❑ ❑
Self-injurious
Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
37
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions ''r= -
(Check one box for each category)
Assessment Areas Mild/ - Moderate/ Hieh/, Comrsients: ' `
None '; Mild Moderate: Moderate High ieh Severe
0 1 11/2 2 21/2 3 3`1/2 .
Inappropriate Sexual ❑ ❑ ❑ ❑ ❑ ❑ ❑
Behavior
Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑
Depressive-like
Behavior ❑ ❑ ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated 'severe', ❑ ❑ ❑ ❑ ❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑
Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑ ❑ ❑ ❑
Involvement with ❑ ❑ ❑ ❑ ❑ ❑ ❑
Child's Family
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR
ASSESSMENT:
(check level of need) ❑ 0 ❑i ❑ 1'h ❑ 2 LI 2'/ ❑ 3 ❑ 3'h
38
(Exhibit Cr
WELD COUNTY DEPARTN1EN I'OF BUN1AN SERVICES
NEEDS BASED CARE
RATE TABLE
RECOMMENDED
LEVEL S RECOMMENDED AGENCY RATE =THERAPY RATE MEDICAL
OF PROVIDER RATE .:NEEDS '
SERVICE ADDENDUM
Level Rate Case Management. , Therapy Level
(Admin.Maint.) - (Admin,Services)
Age 0-10...$16.32
($496) Basic Maint $4.93 day/$150mo Level 0 $0
Age 11-14...$18.05 Therapy not needed or provided
County
($549) No crisis intervention, Minimal CPA by Level 0._$0
Basic
Age 15-21...$19.27 (None)
Maint.
($586) involvement, one face-to-face visit another source, i.e.mental health.
+$.66 Respite Care
($20) with child per month.
$19.73 Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
+$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy,
1
one face-to-face visit per month with Level 1 _$2.9'
($20.39 day/$620 mo) child, up to 4 hours/month.
2-3 contacts per month
$23.01
1 1/2 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo
($23.67 day/$720 mo)
$26.30 Level 2.. $11.51 day/$350 mo Level 2 $9.86/$300 mo
2 +$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy, Level 2..$4.41
two face-to-face visits with child, 5-8 hours a month with 4 hours of
($26.96 day/$820 mo)
2-3 contacts per month group therapy.
$29.59
2 1/2 +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo
($30.25 day/$920 mo)
$32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
3 multiple sessions,can include Level 3..$6.Oc
weekly face-to-face visits with child, more
($33.54day/$1020 mo) and intensive coordination of than 1 person, i.e.family therapy,
multiple services. for 9-12 hours/monthly.
$36.16
3 1/2 +$.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo
($36.82 day/$1,120 mo)
$39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
multiple sessions,can include
4
TRCCF which includes high level of case more Level 4....Dec
Drop Down management and CPA involvement with than 1 person, i.e.family therapy,
($40.11 day/$1220 mo)
child and provider and 2-3 face-to-face for 9-12 hours/monthly.
contacts .er week minimum.
Assess/
Emergency $30.25 day/$920 mo $13.15 day/$400 mo
Level (Includes Respite)
Rate
Admin.Overhead Rate: As of 7/01/r
$6.91 day/$210.00 month
39
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
SERVICES
By: By:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «CPA_NAME»
OF HUMAN SERVICES «MAILING_ADDRESS»
«CITY_STATE_ZIP»
By: By:
County Director's Signature/Date Contractor's Signature/Date
40
CPA Service Providers
2012-2013
FACILITY
CPA NAME ID MAILING ADDRESS CITY STATE ZIP
1 Adoption Alliance 71259 2121 5. Oneda St, Suite 420 Denver, CO 80224
Ariel Child Placement 90205 4251 Kipling St, Unit 500 Wheat Ridge, CO 80033-2899
2 Agency
Commonworks
3 104085 5310 Ward Road, Suite G-01 Arvada, CO 80002
D.B.A. Synthesis
4 Frontier Family Services 38041 1290 Boston Ave Longmont, CO 80501-5810
5 Hope & Home 29867 4945 N 30th Street, Suite 300 Colorado Springs, CO 80919-3152
6 Imagine 21369 1400 Dixon Ave Lafayette, CO 80026
7 Kids Crossing 79752 1440 E Fountain Blvd Colorado Springs, CO 80910-3502
8 Kids Resource Network 1508602 6285 Leham Dr., Suite 101 Colorado Springs, CO 80918
of Colorado Springs
9 Lutheran Family Services 45080 2032 Lowe Street, Suite 200 Fort Collins, CO 80525
Rocky Mountains
10 Maple Star Colorado 90967 2250 S Oneida Street, Suite 100 Denver, CO 80224-2557
11 New Start Youth Services LLC 1528224 PO Box 8653 Pueblo, CO 81008
12 Parker Personal Care 1512100 5394 Marshall Street Arvada, CO 80002
Homes Inc.
13 Quality Life Services LLC 32066 11975 Reed Street Broomfield, CO 80020
14 Smith Agency Inc. 44882 14394 E. Evans Ave Aurora, CO 80014-1408
15 Special Kids Special Families 43184 424 W Pikes Peak Ave Colorado Springs, CO 80905
16 Whimspire CPA 19562 4575 Galley Rd, Suite 400A Colorado Springs, CO 80915-2750
41
Attachment VI
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Group Home/Group Center Care
Services (the "Agreement") between «CENTER_NAME» and 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.
1. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement at a rate of$«PROVIDER_RATE», per day for children
placed within the Group Home/Group Center identified as Provider ID
#«FACILITY_ID». 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.
2. County and Contractor agree that for Children's Habilitation Residential Program
(CHRP) waiver eligible children, the County agrees to pay the federal SSI rate to
Contractor and all other service costs will be billable under the CHRP program.
3. Section I, Paragraph 2. 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. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
6. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
7. Add Paragraph 8 to Section I. The services purchased under this Agreement for Group
Home/Center services may include, but are not limited to: Basic 24-hour care and child
maintenance (food, shelter, clothing, educational supplies and allowance), direct child
care, transportation, administrative overhead, support overhead, service delivery staff,
which may include but are not limited to: Parent training for teens, independent living
training, and mentor/advocate services.
8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
42
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
9. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Contractor
shall be notified by County staff of the date and time of the review.
10. Add Paragraph 15 to Section IV. Actively participate in achieving the child's
Permanency Goal and cooperate with any vendors hired by Weld County Department of
Human Services to shorten the duration of placement.
11. Add Paragraph 16 to Section IV. Have physical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
Contractor. All documentation of these examinations shall be forward to the County.
12. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized
Educational Plan (IEP) for youth designated as a Special Education Student every 3 years
and coordinate reviews every year. If the IEP is due while the child is in placement, the
Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to
the County.
13. Add Paragraph 18 to Section IV. 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;
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.
14. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Residential Child Care Facilities and Child Placement Agencies are not eligible to receive
clothing allowances as outlined in the Weld County Department of Human Services
Policy and Procedure Manual.
15. Add Paragraph 7 to Section VI. 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
43
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.
16. Add Paragraph 8 to Section VI. 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.
17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Human Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
18. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event that the Contractor learns of any actual litigation in which it is a party
defendant in a case, which involves services provided under the agreement. The
Contractor, within five (5) calendar days after being served with a summons, complaint,
or other pleading which has been filed in any federal or state court or administrative
agency, shall deliver copies of such document(s) to the Human Services' Director. The
term "litigation" includes an assignment for the benefit of creditors, and filings in
bankruptcy, reorganizations and/or foreclosure.
44
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
SERVICES
By: By:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «CENTER NAME»
OF HUMAN SERVICES «MAILING ADDRESS»
«CITY_STATE_ZIP»
By: By:
County Director's Signature/Date Contractor's Signature/Date
45
Group Home/Group Center Service Providers
2012-2013
FACILITY PROVIDER
CENTER NAME MAILING ADDRESS CITY STATE ZIP ' <
ID RATE
1 A Kidz Hope Homes Inc. 1401 W Colorado Ave Colorado Springs, CO 80904 1531611 $95.00
2 A Kidz Hope Homes Inc. 1401 W Colorado Ave Colorado Springs, CO 80904 1531612 $95.00
3 Evergreen Group Center 1436 Hilltop Dr. Longmont, CO 80501 61317 $102.00
4 Frontier Family Services 1290 Boston Ave Longmont, CO 80501-5810 84655 $73.01
5 Frontier Family Services 1290 Boston Ave Longmont, CO 80501-5810 1612890 $73.01
6 Griffith Center for Children 8461 Turnpike Drive, Suite 100 Westminster, CO 80031 1531601 $115.00
7 Griffith Center for Children 8461 Turnpike Drive, Suite 100 Westminster, CO 80031 1543863 $115.00
8 Heritage House PO Box 195 Louisville, CO 80027 1520452 $110.00
9 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1530211 $92.05
10 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1534441 $92.05
11 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1536449 $95.34
12 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1541496 $92.05
13 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1542790 $92.05
14 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1545224 $92.05
15 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1549764 $92.05
16 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1551132 $95.34
17 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1552984 $95.34
18 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1555972 $92.05
19 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1594381 $88.77
20 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1597038 $92.05
21 Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80033 1606128 $92.05
22 Maple Star Colorado 2785 Speer Blvd, Suite 340 Denver, CO 80211 13416 $86.00
23 Rocky Mountain Kids 2210 E. LaSalle Street, #219 Colorado Springs, CO 80909 1599808 $93.67
24 Rocky Mountain Kids 2210 E. LaSalle Street, #219 Colorado Springs, CO 80909 1599810 $93.67
25 Smith Agency 14394 E Evans Ave Aurora, CO 80014 1540493 $147.77
46
Attachment VII
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Residential Child Care Facility
Services (the "Agreement") between «RCCF_NAME» and 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.
1. County agrees to purchase and Contractor, identified as Provider
ID#«FACILITY_ID», agrees to provide:
A. Child Maintenance, Administrative Maintenance and Services, which are listed in
this Agreement at a rate of S«PROVIDER_RATE»per day for children placed
within the Residential Child Care Facility unless the child is eligible for the
CHRP program. If the child is deemed CHRP eligible, County agrees to pay the
federal SSI rate to Contractor and all other service costs will be billable under the
CHRP program.
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.
2. Section I, Paragraph 1. County considers the agreed upon rate, outlined in the Weld
County Addendum to this contract, to be all inclusive and shall not pay for additional
treatment fees; i.e. Drug/Alcohol and Sex Offender services.
3. Section I, Paragraph 2. 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. Reimbursement rates for bed hold days may
not exceed the state standard rate for administrative maintenance and administrative
services or may be a reduced rate that is mutually agreed upon.
4. Section 1, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
5. Add Paragraph 6 to Section I. The services purchased under this Agreement as Child
Maintenance, Administrative Maintenance and Services for Residential Child Care
Facilities include, but are not limited to: Food, shelter, clothing, personal needs and
allowance, administration, administrative overhead, support staff, support overhead,
sleep-over staff, direct child care, transportation, therapeutic recreation, service delivery
staff, parent training for teens, independent living training, mentor/advocate, supervised
visitation and all other services as outlined in the Child Specific Addendum. The
anticipated minimum percentage for each item is as follows and will be subject to County
monitoring as outlined in Section VI of this contract:
A. Food, including meals and snacks (25%);
B. Clothing (3%);
C. Shelter, including utilities and use of household furnishing and equipment and
47
daily supervision, including those activities that a parent would normally carry out
to assure protection, emotional support and care of the child (30%);
D. Personal items and grooming care for the child, such as toothpaste, toothbrushes,
soap, combs, haircuts, and other essentials (2%);
E. Other/miscellaneous items considered usual in the care and supervision of the
child, include, but are not limited to, transportation, recreation and overhead
(40%)
6. Add Paragraph 8 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
7. Add Paragraph 9 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
that is not provided within the vendor rate or attached Scope of Service, will need be
negotiated and authorized, in writing by the County, prior to the service being performed.
Any payment for specialized services not authorized in writing will be denied.
8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
9. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Provider shall
be notified by County staff of the date and time of the review.
10. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County
Department of Human Services to shorten the duration of placement.
11. Add Paragraph 16 to Section IV. Have physical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
Contractor. All documentation of these examinations shall be forward to the County.
12. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized
Educational Plan (IEP) for youth designated as a Special Education Student every 3 years
and coordinate reviews every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
13. Add Paragraph 18 to Section IV. 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
48
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
14. Section V, Paragraph 5. Children in Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Human Services Policy and Procedure Manual.
15. Add Paragraph 7 to Section VI. 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.
16. Add Paragraph 8 to Section VI. 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.
17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Human Services and the
49
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
18. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
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
SERVICES
By: By:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «RCCF_NAME»
OF HUMAN SERVICES «MAILING ADDRESS»
«CITY STATE_ZIP»
By: By:
County Director's Signature/Date Contractor's Signature/Date
50
Residential Child Care Facility CHRP Providers
2012-2013
RCCF NAME MAILING ADDRESS CITY STATE ZIP FACILITY PROVIDER
ID RATE
1 Roundup Fellowship 2250 S Oneida, Suite 201 Denver, CO, 80224 45105 $145.98
2 Roundup Fellowship 2250 S Oneida, Suite 201 Denver, CO, 80224 45201 $145.98
3 Roundup Fellowship 2250 5 Oneida, Suite 201 Denver, CO, 80224 45211 $145.98
4 Roundup Fellowship 2250 S Oneida, Suite 201 Denver, CO, 80224 45212 $145.98
5 Smith Agency 14394 E. Evans Ave Aurora, CO 80014 6566 $145.98
6 Smith Agency 14394 E. Evans Ave Aurora, CO 80014 96482 $145.98
51
Attachment VIII
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Specialized Group Home Care
Services (the "Agreement") between «CENTER_NAME» and 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.
1. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement at a rate of 550.04, per day for children placed within the
Group Home identified as Provider ID#«FACILITY ID». 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.
2. Section I, Paragraph 2. 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.
3. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
4. Add Paragraph 6 to Section 1. The services purchased under this Agreement for Group
Home services may include, but are not limited to: Basic 24-hour care and child
maintenance (food, shelter, clothing, educational supplies and allowance), direct child
care, transportation, administrative overhead, support overhead, service delivery staff,
which may include but are not limited to: Parent training for teens, independent living
training, and mentor/advocate services.
5. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
6. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Contractor
shall be notified by County staff of the date and time of the review.
7. Add Paragraph 15 to Section IV. Actively participate in achieving the child's
Permanency Goal and cooperate with any vendors hired by Weld County Department of
Human Services to shorten the duration of placement.
8. Add Paragraph 16 to Section IV. Have physical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
52
Contractor. All documentation of these examinations will be placed in the group home
placement binder.
9. Add Paragraph 17 to Section IV. Meet with the Department of Human Services Group
Home Coordinator for a minimum of two hours weekly (7.709.21).
10. Add Paragraph 18 to Section IV. Work collaboratively with Department staff, mental
health professionals, GAL's, CASA volunteers, and other service providers in arranging
times that the Contractor's home is open to professional visits. Contractor also
understands that the County Department Caseworker and GAL have the right to make
unannounced home visits to check the child's safety, needs, and environment.
11. Add Paragraph 19 to Section IV. Ensure that hired staff are; completing training specific
to the children they service, and are current on all trainings and other requirements as
mandated by CDHS Volume 7 Policy and Procedure Manual section 7.700.
12. Add Paragraph 20 to Section IV. Accompany key professionals to school conferences,
IEP meetings, school-related staffings, Foster Care Reviews and Court Hearings.
13, Add Paragraph 21 to Section IV. Immediately report any significant issue, regarding the
youth, to the youth's assigned caseworker. Issues may be medical, behavioral, legal/
criminal, or educational in nature. If a youth becomes a threat to him/herself or others,
appropriate "critical incident" documentation must be prepared by the specialized group
home parent according to State guidelines (7.701.52), in addition to notification to the
caseworker. While specialized group home parent attempts to maintain the youth at the
group home level of care, the specialized group home parent will be familiar with Weld
County's continuum of care and understand when a child needs to be forwarded or
regressed through the continuum.
14. Add Paragraph 22 to Section IV. 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.
15. Add Paragraph 23 to Section IV. 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;
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.
53
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.
16. Add Paragraph 7 to Section VI. 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.
17. Add Paragraph 8 to Section VI. 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.
18. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Human Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
19. Add Paragraph 10 to Section VI. The Contractor shall promptly notify Human Services
in the event which it is a party defendant or respondent in a case, which involves services
provided under the agreement. The Contractor, within five (5) calendar days after being
served with a summons, complaint, or other pleading which has been filed in any federal
or state court or administrative agency, shall deliver copies of such document(s) to the
Human Services' Director. The term "litigation" includes an assignment for the benefit
of creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
54
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
SERVICES
By: By:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «RCCF NAME»
OF HUMAN SERVICES «MAILING ADDRESS»
«CITY STATE ZIP»
By: By:
County Director's Signature/Date Contractor's Signature/Date
By:
Contractor's Signature/Date
55
Specialized Group Home Care Providers
2012-2013
FACILITY PROVIDER
CENTER NAME MAILING ADDRESS CITY STATE ZIP ID RATE:
1 A.M. Group Home 509 N Sholdt Dr Platteville, CO 80651 1526756 $50.04
2 C & M Group Home 1920 81st Ave Greeley, CO 80634 9875 $50.04
3 Marie Alirez Group Home 1405 26th Street Greeley, CO 80631 70335 $50.04
4 Michael Alirez Group Home 1709 37th Ave Greeley, CO 80634 54150 $50.04
56
Attachment IX
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Residential Child Care Facility
Services (the "Agreement") between «RCCF_NAME» and 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.
1. County agrees to purchase and Contractor, identified as Provider
ID#«FACILITY_ID», agrees to provide:
A. Child Maintenance, Administrative Maintenance and Services, which are listed in
this Agreement at a rate of S <RCCF_RATE» per day for children placed within
the Residential Child Care Facility.
B. Additional services not covered by Medicaid or considered within the above
vendor rate. These additional services/rates may be negotiated on a child by child
basis, based on the needs of the child and in accordance with the Colorado
Department of Human Services Agency Letter CW-06-11-I dated June 8, 2006.
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.
2. Section I, Paragraph 1. County considers the agreed upon rate, outlined in the Weld
County Addendum to this contract, to be all inclusive and shall not pay for additional
treatment fees; i.e. Drug/Alcohol and Sex Offender services
3. Section I, Paragraph 2. 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. Reimbursement rates for bed hold days may
not exceed the state standard rate for administrative maintenance and administrative
services or may be a reduced rate that is mutually agreed upon.
4. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
5. Add Paragraph 6 to Section 1. The services purchased under this Agreement as Child
Maintenance, Administrative Maintenance and Services for Residential Child Care
Facilities include, but are not limited to: Food, shelter, clothing, personal needs and
allowance, administration, administrative overhead, support staff, support overhead,
sleep-over staff, direct child care, transportation, therapeutic recreation, service delivery
staff, parent training for teens, independent living training, mentor/advocate, supervised
visitation and all other services as outlined in the Child Specific Addendum. The
anticipated minimum percentage for each item is as follows and will be subject to County
monitoring as outlined in Section VI of this contract:
A. Food, including meals and snacks (25%);
B. Clothing (3%);
57
C. Shelter, including utilities and use of household furnishing and equipment and
daily supervision, including those activities that a parent would normally carry out
to assure protection, emotional support and care of the child (30%);
D. Personal items and grooming care for the child, such as toothpaste, toothbrushes,
soap, combs, haircuts, and other essentials (2%);
E. Other/miscellaneous items considered usual in the care and supervision of the
child, include, but are not limited to, transportation, recreation and overhead
(40%)
6. Add Paragraph 7 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
7. Add Paragraph 8 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
that is not provided within the vendor rate or attached Scope of Service, will need be
negotiated and authorized, in writing by the County, prior to the service being performed.
Any payment for specialized services not authorized in writing will be denied.
8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
9. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Provider shall
be notified by County staff of the date and time of the review.
10. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County
Department of Human Services to shorten the duration of placement.
11. Add Paragraph 16 to Section IV. Have physical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
Contractor. All documentation of these examinations shall be forward to the County.
12. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized
Educational Plan (IEP) for youth designated as a Special Education Student every 3 years
and coordinate reviews every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
13. Add Paragraph 18 to Section IV. 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.
58
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;
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.
14. Section V, Paragraph 5. Children in Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Human Services Policy and Procedure Manual.
15. Add Paragraph 7 to Section VI. 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.
16. Add Paragraph 8 to Section VI. 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.
17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
59
under this Agreement or other agreements between Human Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
18. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
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
SERVICES
By: By:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «RCCF NAME»
OF HUMAN SERVICES «MAILING_ADDRESS»
«CITY STATE ZIP»
By: By:
County Director's Signature/Date Contractor's Signature/Date
60
Out of State
Residential Child Care Facility Providers
2012-2013
FACILITY RCCF
RCCF NAME MAILING ADDRESS CITY STATE ZIP ID RATE
1 Cathedral Home for PO Box 520 Laramie, WY 82073-0520 17961 $522.00
Children
Cornell Corrections of
2 Texas, Inc., DBA Hector 620 East Afton Oaks Blvd San Antonio, TX 78232 1617541 $242.85
Garza Center
3 Youth Villages PO Box 341154 Memphis, TN 38184-1154 1511780 $390.00
61
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