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Home My WebLink About20122309.tiff MEMORANDUM VS-FM DATE: August 29, 2012 11 TO: Sean P. Conway, Chair, Weld County oard of Commiss;oners _ C �' f 1 f�" ) G O U T FROM: Judy A. Griego, Director, Human SOfvi s Depai tfen-� RE: Weld County Addendum to Purchase C ild Placement Agency Services between the Weld County Department of Human Services and Various Providers to be Placed on the Consent Agenda Enclosed for Board approval are Weld County Addendums to Purchase Child Placement Agency Services between the Department and Various Providers. These Addendums were reviewed under the Board's Pass-Around Memorandum dated August 8, 2012, and approved for placement on the Board's Consent Agenda. Below are the major provisions of the attached Agreements: No. Facility Name/Term Type of Facility/Location Daily Rate 1 Commonworks D.B.A. Synthesis Child Placement Agency Services $16.32-$40.11 July 1, 2012—June 30, 2013 Arvada, Colorado 2 Frontier Family Services Child Placement Agency Services $16.32-$40.11 July 1, 2012—June 30, 2013 Longmont, Colorado 3 Hope & Home Child Placement Agency Services $16.32-$40.11 July 1, 2012—June 30, 2013 Colorado Springs, Colorado 4 Imagine Child Placement Agency Services $16.32-$40.11 July 1, 2012—June 30, 2013 Lafayette, Colorado 5 Kids Crossing Child Placement Agency Services $16.32-$40.1 1 July I, 2012—June 30, 2013 Colorado Springs, Colorado 6 Kids Resource Network of Child Placement Agency Services $16.32-$40.11 Colorado Springs Colorado Springs, Colorado July I, 2012—June 30, 2013 7 Lutheran Family Services Rocky Child Placement Agency Services $16.32-$40.11 Mountain Fort Collins, Colorado July 1, 2012—June 30, 2013 8 Maple Star Colorado Child Placement Agency Services $16.32-$40.11 July 1, 2012—June 30, 2013 Denver, Colorado 9 New Start Youth Services LLC Child Placement Agency Services $16.32-$40.11 July 1, 2012—June 30, 2013 Pueblo, Colorado 10 Parker Personal Care Homes Inc. Child Placement Agency Services $16.32-$40.1 I July 1, 2012—June 30, 2013 Arvada, Colorado rn 11 Quality Life Services LLC Child Placement Agency Services $16.32-$40.11co July 1, 2012—June 30, 2013 Broomfield, Colorado 12 Smith Agency Inc. Child Placement Agency Services $16.32-$40.11 July 1, 2012—June 30, 2013 Aurora, Colorado `" 13 Special Kids Special Families Child Placement Agency Services $16.32-$40.11 July 1, 2012 —June 30, 2013 Colorado Springs, Colorado et9twity 0,44„.„6„, et .X99 c O/ 7 Y-ao-4? iv/e 083 14 Whimspire CPA Child Placement Agency Services $16.32-$40.11 July I, 2012—June 30, 2013 Colorado Springs, Colorado If you have any questions, give me a call at extension 6510. WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Commonworks D.B.A. Synthesis 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 th 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#104085. 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 Weld County SS-23A Addendum 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 2 Weld County SS-23A Addendum 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: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX ITRAILS CASE ID jDOB M F I WORKER COMPLETING ASSESSMENT !HIM IRATE OF ASSESSMENT AGENCY NAME PROVIDER NAME I 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 01%)2 round trips a week ❑2)3-4 round trips a week. ❑2%z)5 round trips a week O3)6 round trips a week ❑3'/z)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 ❑l)Once a month ❑1%)Two times month O2)Three times a month O2%)Once a week O3)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 or special education plan? ❑ Basic Maint.)No educational requirements ❑l)Less than a ''/z hour per day ❑1%z) %z hour a day O2) 1 hour a day O2 %z) 1'/:-2 hours per day O3)2'/z-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? O Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%z) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3%z)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond aue appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? 0 Bask Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/z) 11 to 15 hours per week ❑3) 16 to 20 per week O3%)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.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. ❑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) ❑I)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a.1.1:, to this child. C''!..";:',.'''.1'''.' [ Ta- - to 7 ,f f :t' * 1 's ',1 5 i ...1 .2.1.-'•-,..,%4":C. :fir • x y t, h `A7+ ',r.� 's t+cx� s t 44`.1 t"' "' '4"3 . .' } ''k. n �. i yea a� .m .. r. I Thin w § . "° �} S'}t.� °la r e . .- j'k ,n w p z« a t,=l,• e �� .,: "'�5.�A,S�3�P ti �� .. '�YC Sd�c,°.�.` . ..+�° . ro3 v'�s'S'#3Rr`M 3....>._.r._s.. �..... r.,� ..,, ... .._ �' .�..°..v Aggression/Cruelty to Animals ❑ 0 ❑ ❑ 0 ❑ 0 Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ 0 0 0 0 0 Substance Abuse El 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis O 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses O 0 0 0 0 0 0 5 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS • NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. ;1'047::' , ?" "v,:,r y} r, yw it s 9 v x a.k ;.' r n v s 'hl; .+a.,t ( ate +tea #� �'{ tlyl r Pv�.T i i ✓ Vi x3t 'c it .s.y''itvq r "'"'� '°� s `%::,..� .,b*;.°^p* �MS 's k r i !t' t .i ,,, ;,..c.. i 9 7 3' Sx x may • °�++*. „ 'ati a ..., _d .. • 81!," x s3i ha .... A,t,l t 'aka, S"9Eds.' '.^' ,,.rlu�,'"i, Inappropriate Sexual Behavior El 0 0 ❑ 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ 0 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ 0 0 Medical Needs (If condition is rated"severe', ❑ ❑ ❑ ❑ ❑ 0 ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ 0 0 0 Requires Night Care ❑ 0 0 ❑ 0 0 0 Education 0 0 0 0 ❑ 0 0 Involvement with Child's Family 0 0 0 0 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/2 ❑ 2 ❑ 2%2 ❑ 3 ❑ 3'/z 6 Weld County SS-23A Addendum • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE : } " +,.i r�s y. a as £a=•. . z'.i t a+4 34 ":171',:;:::'!"::::::71 jiiiri i tLie: r. g ii,„td "z. 3�.�`,S t 'e.5.n,t xlrm'"'a ,�. :.ar c 'tt'*" . { x z; .g r kni�� r �,�'y C �; i '.�a�' § s r �: • r w e :::7 1`ei`'hw.k+,'f 5 f- �r,9"a t`��'a w ik §` fdl * R 1p,L... �,.'v:'4'i bi `:''° ' t}Au:A ,, a k:faw m ..'fat ielt sr jetfet ..S` xP ' 4tt� ��i 5 �� i u xw u_ • kuY+'e e x ° '" .v�ica . . .+, c a:ti,-.� .ue�,.:. 1� k.. rh nA4. u'�::;!••• � .. .,.. ;.p'4 5..•,.�: Age 0-10...$16.32 r'' ($496) - Basic Maint $4.93 day/$150mo bpi: Level 0 $0 ? County c Age 11-14...$18.05 ' Therapy not needed or provided .5_ ll Basic ($549) No crisis intervention,Minimal CPA by Level 0...$0 Masi Age 15-21...$19.27 .; (None) t�eo ($586) involvement,one face-to-face visit another source, i.e.mental health. `z kf +$.66 Respite Care a•-' fiR ($20) with child per month. a ,. "a r5 $19.73 # Level 1 $8.22 day/$2ilie 50 mo Level 1 $4.93/$150 mo 1x''�' +$.66 Respite Care Minimal crisis intervention as needed t Regularly scheduled therapy, _° ^° one face-to-face visit per month wRh y' Level 1 ...$2.99 rifil ($20.39 day/$620 mo) child, up to 4 hours/month. .444 2-3 contacts per month , ;, iiiiiiiiii $ $23.01 ":"...,72 1 1/2 "�. +$,66 Respite Care Level 1 1/2 $9.86 day/$300 mo '9' 4,-11 ---- ----------- --------- ° ($23.67 day/$720 mo) gib!! F,+ , i. '� $26.30 h l Level 2 $11.51 day/$350 mo ;e.741 Level 2 $9.86/$300 mo ter' 2 Fl +$.66 Respite Care o- Occasional crisis intervention as needed, i Weekly scheduled therapy, i Level 2..$4.47 ` two face-to-face visits with child, fr. 5-8 hours a month with 4 hours of - ray ($26.96 day/$820 mo) ( ,' Nt` 2-3 contacts per monthfin'_.; group therapy. '�)'� y: , �.. $29.59is r£ 2 1/2 +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo �' -------- pa,ki ($30.25 day/$920 mo) i. ; $32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo p 114, +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly ;fie 41 ;; multiple sessions,can include a' 3 Level 3..$6.02 weekly face-to-face visits with child, B more ;s witi ($33.54day/$1020 mo) ° ' and intensive coordination of !pi,: than 1 person, i.e.family therapy, !I iiir11 P2. multiple services. ' for 9-12 hours/monthly. '1 $36.16 r ^we' � a 3 1/2 +$.66 Respite Care 1 Level 3 1/2 $16.44 day/$500 mo itx ($36.82 day/$1,120 mo) hisa nx rIniiii 3 °iiiiIssi $39.45rvi.iiii .7O Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo +$.66 Respite Care Ongoing crisis intervention as needed, '- g y y ' Re ularl scheduled weekl 4 .,;, multiple sessions,can include which includes high level of case more TRCCF 9 Level 4....Neg. Drop Down ` ? ($40.11 day/$1220 mo) m management and CPA involvement with than 1 person,i.e.family therapy, child and provider and 2-3 face-to-face for 9-12 hours/monthly. ii,4 x Li;i. .;Y contacts 'er week minimum x iiiAssess/ @ 'Iv i" 4+ Emergency Kip $30.25 day/$920 mo P $13.15 day/$400 mo L�' s mid t'1" --- ---- Level (Includes Respite) tiii°,• Rate S OM Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum " IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the B ;� WELD COUNTY BOARD OF S Lam SOCIAL SERVICES, ON BEHALF ad OF THE WELD COUNTY �o.q, ., DEPARTMENT OF HUMAN ism 4t r� SERVICES By �I�/ ,i. �1./ %I� ` � ( IAI By: Depu r lerk to the Board " Chair Signature Pivt.m Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT Commonworks D.B.A. Synthesis OF HUMAN SERVICES 5310 Ward Road, Suite G-01 Arvada, COQ 80002 By: By: v a,LILY ti i n Facia... -1/2,311z Co y Director' Signatu> Date Contractor's Signature/Date 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Frontier Family Services and Weld County Department of Human Services for the period from July 1,2012 through June 30,2013. The following provisions, made this ,2p day of 4t , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of th 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#38041. 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 q Weld county 55-23A Addendum SO, 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 2 Weld County SS-23A Addendum 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: 3 Weld County SS-23A Addendum (Exhibit B) • WELD COUNTY DHS • NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# {.SEX I r1'RAILS CASE ID (DOB WORKER COMPLETING ASSESSMENT rim �M I (DATE OF ASSESSMENT I AGENCY NAME PROVIDER NAME I 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 ❑1)One round trip a week 011/2)2 round trips a week 02)3-4 round trips a week. ❑2%)5 round trips a week 03)6 round trips a week 03%)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 01)Once a month ❑1%)Two times month 02)Three times a month 02%)Once a week 03)Two times a week ❑3%)Three times a week or more P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑I)Less than a'/a hour per day O1'A)1/2 hour a day ❑2) I hour a day 02 %) 1'h-2 hours per day 03)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? ❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week ❑1%)5 to 7 hours per week 02) 8 to 10 hours per week ❑2'A) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond a¢e appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week O1%)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%)21 or more hours per week A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 011/2)Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County 55-23 A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a.il 1 to this child. w°:. a a 1-'s i :::,:i AT i W s' '' • .-4.� S -,1 * ,e� s y k ' ", , i`' £ "` .01 z ". i +7Ex5`,,,,.9ack r` b � - Lt ' 2 'r Y 'z s t A ₹ t '�" rv�w,+i*i' �iZN k€3, ` ,"'yt C ', r 1'. s s y a a .1,v,. ,i s :,, may" . 4.-,,"t k-,i iii �t� '4* . , t,t-,'>a t,[+^ ,ircr <z r x i Att'may Se"t 4,�' rv,1 IR:n 5, a}t '#.k r* i 4 k' s 'Stb. c , zi a, ,4 i s d 4 < w at as 4 f i �' 1 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ 0 Destructive of Property/Fire Setting 0 ❑ ❑ ❑ ❑ ❑ ❑ Stealing ❑ ❑ 0 0 0 ❑ 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ 0 0 Substance Abuse ❑ ❑ 0 ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ 0 ❑ ❑ ❑ 0 0 Runaway ❑ 0 ❑ 0 ❑ ❑ 0 Sexual Offenses ❑ 0 ❑ 0 ❑ 0 ❑ 5 Weld County SS-23A Addendum • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..l to this child v>r v` y ,��'� 't, ye- '� It m r 9 ti tit a .#ftyr � ;,„,.:,o,, x 1 a s�.�1 � fir " .. �� „�-'! ,aF ' : j '., °; ' ,gin c? eS ,° .d'- ' :7�tY ' G Y l C I rve i..,;' �°y'4 ''_ i a.1 : _: y.:.., .:.' -T-7:.. _.�: 4^e ez_ _. E•mtea ..s=::rya a.:t.h� �w..e.+......§ ...._._,-: _ cca ....... ' " ,s; Inappropriate Sexual Behavior 0 0 ❑ ❑ ❑ 0 0 Disruptive Behavior ❑ ❑ 0 0 0 0 0 Delinquent Behavior ❑ 0 0 ❑ 0 0 ❑ Depressive-like Behavior ❑ ❑ 0 ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe', ❑ 0 ❑ 0 0 ❑ 0 please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 ❑ Eating Problems ❑ 0 ❑ 0 ❑ 0 ❑ Boundary Issues ❑ 0 0 0 ❑ 0 0 Requires Night Care ❑ ❑ ❑ ❑ 0 ❑ 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'A ❑ 3 ❑ 3% 6 Weld County SS-23A Addendum I '• ' (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 1j 414 51111 3 144.12-4§,�- ry n ra ixx�"ta.,y s.' x c!1 '( _ ,ax. 1 %: a na ♦. .u}v.f° 1 . . a . 1;"7.,.F.nro- ` s� a :- sgt`4 a '-� i` y ' t � r'1 5,, '"•„ty i L. } r i 1 t ar o �, to fl� t` ,•-+4ee4: r' . . 'a'` ,. r"I a1 ''1 psr: ?, x ,. i +Pf4? a 'k" r. *•i 3+ v;... Y'R'sat 4.,a gtaN ti�,sr . n;i.D ; r'a' u" A 55 '}" ( }"f{ ✓ r y4 p.e7 � +} '�� t 'il �°:c 4Aa1 n va '. 'w 4 ':;; :! a i a acre}. , a w .1 Ai (idI. ...,�,, `4 t . M .. �x kr4xt'§ e 4', h P u b.#'r ,,r s " • 't h li . Age 0-10...$16.32 p ($496) Basic Maint $4.93 day/$150mo Level 0 $0 r "j. Age 11-14...$18.05 `, County Therapy not needed or provided ; Basic ($549) No crisis intervention, Minimal CPA :OA by r Level 0...50 Mamt Age 15-21...$19.27 40,0 a (None) ($586) A involvement, one face-to-face visit another source, i.e.mental health. a +$.66 Respite Care 1 i!i4 el $20) with child •er month. 11' th iiir i' $19.73 =ti 5•II Level 1 $8.22 day/$250 mo r Level 1 $4.93/$150 mo . (_ 4.11 .4ki f 1 ith +$.66 Respite Care Minimal crisis intervention as needed, .,, Regularly scheduled therapy, •"f one face-to-face visit per month with Level 1 ...$2.99 ($20.39 day/$620 mo) d child, up to 4 hours/month. 2-3 contacts per month *.zw $23.01 1 112 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo ; ($23.67 day/$720 mo) ' .p° $26.30 lar Level 2 $11.51 day/$350 mo ' Level 2 Y k#.. $9.86/$300 mo .� 1 2 +$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy, 14 i1 _,; Level 2..$4.47 tir4 61 two face-to-face visits with child, 5-8 hours a month with 4 hours of e ($26.96 day/$820 mo) s i . 2-3 contacts per month t ':1d group therapy. ,��'„i it $29.59 "'i rr. 2 1/2 +$.66 Respite Care Level 2 1/2S A` . P $13.15 day/$400 mo ; ($30.25 day/$920 mo) Jira $32.88 Level 3 1.a $14ii4i .79 day/$450 mo t,'` Level 3 $14.79/$450 mo ' ..`. ni +$.66 Respite Care i Ongoing crisis intervention as needed, Regularly scheduled 9 Y weekly 1 3 multiple sessions,can includey Level 3..$6.02 8:. weekly face-to-face visits with child, a' more ($33.54day/$1020 mo) ,: ii4 and intensive coordination of _;r than 1 person, i.e.family therapy, 21 multi•le services. 4,5 for 9-12 hours/month) :rt ax $36.16fRII z , i 3 1/2 +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo '`t'• ': ($36.82 day/$1,120 mo) $39.45 �0 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo f 61 +$.66 Respite Care Ongoing crisis intervention as needed, :,:ill' Regularly scheduled weekly ;'. 4 1,Y: multiple sessions,can include . TRCCF which includes high level of case a more F. Level 4_..Neg. Drop Down management and CPA involvement with ' .. ($40mit ti .11 day/$1220 mo) 9 ,2.1 yr?t than 1 person, i.e.family therapy, child and provider and 2-3 face-to-face a for 9-12 hours/monthly. tel ella d g VA contacts •er week minimum. '!1%' iki tl' + RS Assess/ Emergency $30.25 day/$920 mop' Level (Includes Respite) �, $13.15 day/$400 mo ' ., ffi Rate DI La or it Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum • • ' 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 I DEPARTMENT OF HUMAN SERVICES 1/42 BY: ..�/ .i �• ►ice � :� �L,• • '�, By: (4A9a Deput Plerk to the Boa '�� 1 Chair Signature Protern Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT Frontier Family Services OF HUMAN SERVICES 1290 Boston Ave Longmont, CO 80501-5810 By: Co t Directo 's Sign a/Dat Contractor' ate ao/02-a369 S Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Hope & Home and Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this a0 day of , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of th 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#29867. 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 a0/a-07 3002 Weld County SS-23A Addendum 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 2 Weld County SS-23A Addendum 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: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# riEX F ITRAILS CASE ID 'DOB WORKER COMPLETING ASSESSMENT HH# ATE 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 ❑I)One round trip a week 01%)2 round trips a week O2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week ❑3%)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑I)Once a month D1%)Two times month O2)Three times a month O2%)Once a week O3)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 or special education plan? 0 Basic Maint.)No educational requirements DI)Less than a %hour per day 01%) %hour a day O2) 1 hour a day O2 'A) 1'/r2 hours per day O3)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? ❑ Basic Maint.)No special involvement needed DI) Less than 5 hours per week 01%)5 to 7 hours per week O2)8 to 10 hours per week O2%) II to 14 hours per week 0 3)Constant basis during awake hours O3%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week O2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%)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.) ❑l) Face-to-face contact one time per month with child and minimal crisis intervention. O 1%) Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O 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 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 4 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child mit;W'ite# ",. era E 'a#;,,# 4. aui { & t: I .,f' k. i 'ti, '}��'Y ri §{'' v z� a'y#.. k' s 8 a n zw wE ti - ++ ,� °# { u *a .r 4 4 ivr �xxF r „f ' z;.it? T +m' ' t `� t "*c �gg 5�� t °'ts �" l` a itEz5,. rwitco w A ,...t a, r.*-- C rw °, P; e .6. lJh.4Itikart, :. .:{`Li'a'�S; '�. a ...i � .,..,...w-.a s�,«.ma::e .+ a . .. ••,,,.,„,,,,&.,a Aggression/Cruelty to Animals O ❑ O ❑ El O O Verbal or Physical Threatening ❑ ❑ El ❑ O O Destructive of Property/Fire Setting 0 0 El O O El O Stealing ❑ 0 0 El 0 El Self-injurious Behavior ❑ 0 ❑ ❑ 0 0 0 Substance Abuse El 0 0 ❑ 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 O O O O Enuresis/Encopresis 0 0 0 0 0 0 0 Runaway ❑ ❑ 0 ❑ ❑ 0 0 Sexual Offenses ❑ ❑ ❑ 0 ❑ ❑ ❑ 5 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavtor/intenstt of conditions which create the need for services that a.8I to this child. t -tee v -wx^ - tilt " £0,2 �a-x_„ a a • a xr''' %5 s �x au IZ IL' ' ; y a r F . vl� t. iN" ° Yr Y � , `� ,,,,.„ a Iii ,d. 46-s a • 3V, x'R ^ Inappropriate Sexual Behavior 0 ❑ ❑ ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ 0 ❑ 0 0 Delinquent Behavior ❑ 0 0 ❑ 0 0 0 Depressive-like Behavior ❑ 0 ❑ ❑ ❑ ❑ 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ 0 Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'h ❑ 3 ❑ 31/2 6 Weld County SS-23A Addendum / (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE > s-Ps. e i s #" r Wirti 'k.'F°h >+ f k v �4$ t o I' j p 4 i Z lY A' yA r S '�gi $`cv scs �iyzVt 5 35 3 1.l • • '5 ro. As� a,, . , ar TA!! s {"44'4 "s?T .y�C,,,Y c i e .,g u{ as r a srt i�� ",�`. Nfg 1q�� E °� .v.a. 'd'�'a :,k��"��i rei�'"""tty d�','sf�,�3Xw�r :� +'fi% w r t '`� r' a �j'`uSjakii;PWRZW443iiii TO S;T4�'r413�N . AW y'"+n a x , "` ...,,:,s.4! s E:3ta ti>~ s fi{ `"1° d.'iltili 's iitAtafrzKg4afeitti i t:9ia lificti" &r.� t `,,5 w,.r.a. x r... ',. >a.r S.,+..:. St v .r . :_.s,..,L;....?d.43 E�' Age 0-10...$16.32 '�, ($496) Basic Maint $4.93 day/$150mo 'tm Level 0 $0 ,;e„ County 04 Age 11-14...$18.05 i Therapy not needed or provided ia. Basic ($549) No crisis intervention,Minimal CPA • bygtS Level 0...$0 Maint. On Age 15-21...$19.27 1 (None) :, ($586) involvement,one face-to-face visit another source, i.e.mental health. r +$.66 Respite Care ,8, f= ($20) with child per month. 144 x s $19.73 Level 1 $8.22 day/$250 mo Vii.4 Level 1 $4.93/$150 mo ,< S„e +$.66 Respite Care Minimal crisis intervention as needed, Sid Regularly scheduled therapy, ^v' 1 one face-to-face visit per month with •.:44 Level 1 ...$2.99 ($20.39 day/$620 mo) til child, up to 4 hours/month.itp 2-3 contacts per monthim ' t"," IS' $23.01 Kr ,(}, 1 1/2 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo +*.a Si ($23.67 day/$720 mo) "hi irkiN $26.30 Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo Y.•:•1.:. 2 +$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy, :' 4` Level 2..$4.47 4't*k0 6'a.. ($26.96 day/$820 mo) y two face-to-face visits with child, s: 5-8 hours a month with 4 hours of " et 2-3 contacts per month group therapy. ‘11S. eras eitm $29.59 ?g n ,2e 2 1/2 +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo ` FM ($30.25 day/$920 mo) ."' x41.: rig EM nF�4 k $32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo +$.66 Respite Care Ongoing crisis intervention as needed, i. Regularly scheduled weekly Tz 3 multiple sessions,can include Level 3..$6.02 weekly face-to-face visits with child, more N.r-- �: ($33.54day/$1020 mo) - .1 and intensive coordination of than 1 person, i.e,family therapy, s 140 1 mg multiple services. trn for 9-12 hours/monthly. ttA $36.16 ' 31/2 +$,66 Respite Care Level 3 1/2 $16.44 day/$500 mo " 0 -------- ($36.82 day/$1,120 mo) raitilT (' I et ittl $39.45 trii Level 4 $18Rill .08 da /$550 mo rpV "'y Level 4 $14.79/$450 mo +$.66 Respite Care r Ongoing crisis intervention as needed, Regularly scheduled weekly i1• 4 x' multiple sessions,can include : ; TRCCF which includes high level of case t more ;} Level 4....Neg. Drop Down ° management and CPA involvement with t'.9 ($40.11 day/$1220 mo) 9 � than 1 person, i.e.family therapy, •11child and provider and 2-3 face-to face tri for 9-12 hours/monthly. '',,•, : POI; itat4i t.4 contacts .er week minimum . Fwd d .Nt Assess/ __ __________ K :: Emergency .:: $30.25 day/$920 mo $13.15 day/$400 mo --------------- -- "-`� ___-_--- Level (Includes Respite) '::-. Rate .s"'{ Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum 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 Slid®� OF THE WELD COUNTY 7-5 DEPARTMENT OF HUMAN 1/42 SERVICES 461 ,r* By: / _ /�.t i' !� / %��: ` F � By: Deput clerk to the Board Chair Signature Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT Hope & Home OF HUMAN SERVICES 4945 N 30th Street, Suite 300 Colorado Spri s, O 80919--3152 By: `' B 3 /) Cou Directo 's Sign t e/Dat o tor's ignature/Date &'t9/& 7362 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Imagine and Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this 3 day of , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of e Agreement remain unchanged. 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#21369. 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 cct/a7--o7. 1 Weld County SS-23A Addendum 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 2 Weld County SS-23A Addendum • 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: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# {.SEX TRAILS CASE ID IDOB �l F WORKER COMPLETING ASSESSMENT HH# 1DATE 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 DI)One round trip a week 01%)2 round trips a week ❑2)3-4 round trips a week. ❑2''/)5 round trips a week 03)6 round trips a week ❑3'/:)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 01)Once a month 01%)Two times month 02)Three times a month ❑2%z)Once a week 03)Two times a week 03%)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 or special education plan? ❑ Basic Maint.)No educational requirements 01) Less than a %hour per day ❑1'/a)%hour a day 02) I hour a day 02 '%) 1'/z-2 hours per day 03)2'/1-3 hours per day 03%)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 ❑l)Less than 5 hours per week 01%)5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week 0 3)Constant basis during awake hours 03%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/:) 11 to 15 hours per week ❑3) 16 to 20 per week 03%)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.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%)Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T I. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) 01) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County SS-23A Addendum •• (Exhibit B) WELD COUNTY DRS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit yoff�conditions which create the need for services that a..ly to this child. �6 p, t w v .r9 �`�'5P,* #�Y e s . y k : 1-t�x'may.z : ! } 4n.e .2.,7.` Zi i' y x -": "t.: " r ft '�' 'j&. 3. Ftlihr'"s + 2 n . _ .e � r K yv,.r . ,/ are r• it ' ry <:i NSF 114,1. ,.2 r t 4' "`a rrf .i . v oigtqw,ea� ` s�, e`-',7.- , Y i'g fy" utt :f.c is ,r ' :itT. ',III?4x., x r" . z i{1 Aggression/Cruelty to Animals ❑ 0 0 ❑ ❑ 0 0 Verbal or Physical Threatening ❑ ❑ ❑ 0 0 ❑ 0 Destructive of Property/Fire Setting 0 El ❑ ❑ El 0 0 Stealing ❑ ❑ ❑ 0 0 Cl 0 Self-injurious Behavior ❑ ❑ 0 0 0 0 0 Substance Abuse ❑ 0 ❑ ❑ ❑ 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑ ❑ 0 ❑ Enuresis/Encopresis ❑ 0 ❑ ❑ 0 ❑ 0 Runaway ❑ 0 ❑ 0 0 ❑ 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 5 Weld County SS-23A Addendum • (Exhibit B) • • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. °" ! �.u/ 5"' � >a g r :, : ...7;',Y;`• v'' 'r 4, 111 11t s 1101111111S11.11- -t.:.' r11,t 11-Y O'd11°'£ ,� 11S11111111:1111S/11111.4,114111:111144411111.1.1111911,111111111A' y 4..111.1111.11 A11,1 11c" i 1141”11.1 1141.11111:112-^“-111.1, i111111 '1101111114 '� '' 1 1. �1. 11'4 111r1 i K � s � i w z p 'x'$ X i .111111 1 .a r."-!,:t citg : .... ,i.rk ,z-•I '?:..emu .g •»,;,: ,u 'i.. w w ,, l > „Ii n 34t Pan,1y' ;o 44:i a r t,. s`' 1;11105:11131:1111111111:12'2:111,1111.1913411,:211%; ^ x 4'1.., '-'. 1 f, xi .A it t F 3- t.r t > k" °s s: "s • ,.r:*. :c a""�, l # ), .. i °xt .*t 'r • �y,� '��,iris Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ 0 0 ❑ 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ 0 0 ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ 0 0 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ 0 0 0 0 ❑ 0 Requires Night Care ❑ ❑ 0 0 ❑ 0 0 Education ❑ ❑ 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2% ❑ 3 ❑ 3'/z 6 Weld County SS-23A Addendun (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 1, tI t s^``'` ''q' � .. §b rt"+:: v i4 tom_* =i s us ro i 2 til 5 i 4 a .' te. $,'.'1 "a :Ei : i�'ay 4j°�, ;!.:fi ..:42 ' Lrt. 5 i4PO i s:i�' i x v i y :I ,a " s 4s t r s • y illterlSellillfir' '',„�A a• 'tt' _ ;$ yy�Q.. � in 'a@aP i�.aY.hN `f : ; ti5°t k r;:+.+.:-1•';:„4::,•;;;:;+-,,,, s4,v t x Y 46..h r�-' ,'i�" r � ry P... 'sv+ 5afi� v,, ya'Pr 2r_ a s?Y a a v r i ac `s >' `f��yrlit '"'4 tx .' va `" a fy Nk s, ¢ti4ixAb�^'ti7 ! '; z ' `� r "'�.: +T t :4�,'V9S � � �.a+:r.��i.,.i F— .'�: �.c,»uutii�' 9 �� :;:�A vd�,uaulu, c:.a."°...i .,,:s' k'.vaa. �,, s' . .t, . ..._`.,se :24 Age 0-10...$16.32 +, ' 3 - -- ($496) Basic Maint $4.93 day/$150mo j Level 0 $0 ;+ County Age 11-14...$18.05 Therapy not needed or provided "' Bosky ($549) No crisis intervention, Minimal CPA ,'tt°°'' by PR Level 0...$0 Maint. Ot. Age 15-21...$19.27 tfas i (None) ($586) • involvement,one face-to-face visit another source,i.e.mental health. ,N,__'1�" LI 4 +$.66 Respite Care ($20) with child per month. !;!'1 'v ° r $19.73 'k Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo 1 L":4- +$.66 Respite Care Minimal crisis intervention as needed, t�°" Regularly scheduled therapy, ` one face-to-face visit per month with T Level 1 ...$2.99 ($20.39 day/$620 mo) Ili child, . up to 4 hours/month. VA rst2-3 contacts per month -!ft-.1 r $23.01 4! ieat 1 1/2 +$.66 Respite Care ; . Level 1 1/2 $9.86 day/$300 mo ' "il ($23.67 day/$720 mo) ,,,,ti ' �:Lm gii it i $26.30 Level 2 $11.51 day/$350 mo ",,,,Ilii Level 2 $9.86/$300 mo 2 +$.66 Respite Care 1/4 Occasional crisis intervention as needed, � Weekly scheduled therapy, R Level 2..$4.47 ,,sr: 74 ($26.96 day/$820 mo) two face-to-face visits with child, ?al 5-8 hours a month with 4 hours of : ra go, 2-3 contacts per month q; group therapy. r $29.59 ,'" '+ :,. 2 1/2 - +$,66 Respite Care . , Level 2 1/2 $13.15 day/$400 mo '; ---------------------- i ($30.25 day/$920 mo) rye $32.88 t Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo til 311 +$.66 Respite Care 4 Ongoing crisis intervention as needed, tra Regularly scheduled weekly 3 multiple sessions,can include Level 3..$6.02 weekly face-to-face visits with child, more s, , A.p ($33.54day/$1020 mo) and intensive coordination of .Nk than 1 person, i.e.family therapy, st4^ j int t k.. i„,;, multiple services. ?<,k= for 9-12 hours/monthlyLim . ; ,' $36.16 ,.214 :"�€.3 3 1/2 -.. +$.66 Respite Care t . Level 3 1/2.........$16.44 day/$500 mo `r�i"^P ($36.82 day/$1,120 mo) a 'Vitt tit $39.45 Is Level 4 $18.08 day/$550 mo ?', Level 4 $14.79/$450 mo Itge +$.66 Respite Care Ongoing crisis intervention as needed, ' Regularly scheduled weekly _t 4Iii ,t multiple sessions,can include bs TRCCF which includes hi h level of case 'i 9 � more s Level 4....Neg. titDrop Down kil ($40.11 day/$1220 mo) et management and CPA involvement with ,.,C0 than 1 person, i.e.family therapy, 411 kip child and provider and 2-3 face-to-face 1r for 9-12 hours/monthly. ' s o contacts per week minimum. '"w:;`.A== �s Assess/ - t' a. Emergency $30.25 day/$920 mo .% Level (Includes Respite) $13.15 day/$400 moIt — •,�, ---_----- :i, r. Rate r4 $"� w Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum 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 fir IS La DEPARTMENT OF HUMAN • ger =� SERVICES 1/42 ��nry 1161 � �e By �ii �' 11 ! %L��/'�? 'tom By: Dep F"lerk to the Boar:��'�� Chair Signature ROAM Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT Imagine OF HUMAN SERVICES 1400 Dixon Ave Lafayette, CO 80026 By: By 7 / 712s C ty Direc or's Si ature/ to 'Contractor's Signature/Date pia- a3oy 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Kids Crossing and Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this / 7 day of (rut , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the greement 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#79752. 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 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. 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 0,2O/c7-0730 Weld County SS-23A Addendum 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 2 Weld County SS-23A Addendum 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: 3 Weld County SS-23A Addendum (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# M X RAILS CASE ID IDOB F WORKER COMPLETING ASSESSMENT IIH# 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 ❑1)One round trip a week 01%)2 round trips a week ❑2)3-4 round trips a week. O2%)5 round trips a week O3)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? O Basic Maint.)No participation required DI)Once a month 01%)Two times month ❑2)Three times a month ❑2%)Once a week O3)Two times a week ❑3'%z)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 or special education plan? ❑ Basic Maint.)No educational requirements DI)Less than a''/S hour per day DI%) hour a day ❑2) 1 hour a day O2 %) ''/:-2 hours per day ❑3)2'/z-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? ❑ Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1%)5 to 7 hours per week O2) 8 to 10 hours per week O2%) 1 I 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 age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week O2) 8 to I0 hours per week ❑2'/:) 11 to 15 hours per week ❑3) 16 to 20 per week O3%)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.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. ❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0)Not needed or provided by another source(i.e. Medicaid) ❑l)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County SS-23A Addendum (Exhibit B) ' WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. '•111.1 .t 'v" a tH aY+ 7 j +vq•his,•-.Y.i..aZi gyp. e vk row % �1Irl u" \'x.1, 4. i;. 'i 4Y Exx a >%, F § r 4 4 �dl.+ �3 tY mirtiterczg t 1 t r,+a t;r v R 1 z ,x 4 r ev ff= l •• s . ,.� 9 i s k3� `'l"'° §s mx t�e :''v'�tip a A . ` •k " 'y. Aggression/Cruelty to Animals 0 0 0 0 0 0 0 Verbal or Physical Threatening ❑ ❑ 0 0 ❑ 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 ❑ 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ 0 ❑ ❑ ❑ Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway O ❑ 0 0 0 0 0 Sexual Offenses O 0 0 0 0 0 0 5 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Q{, Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. ,. jit t ca t 'P + � { t_ ?,S p ' 1 I s i� 4 . . $ .'y,,.:-.' '+ : r3` trrs,� ' k°e :aa,..1..:,F 4'; , ._. As.?* ti -r.,'-..::,.,. �s ,t. J - '4 .y iW iaism l `Evi d"r 4 f h \ 4 1 4 4$5e '414 & .ri y '3� u a'vjyam ° ` v 1. P a + jd c `.a�....a;.�.:.._ -' ..' a � �. 'Lilt- _...5u.�aC,.,'f_,....s 3s = . .,at. : r.x� _ .6 Inappropriate Sexual Behavior 0 0 ❑ 0 0 O O A Disruptive Behavior ❑ ❑ ❑ 0 0 ❑ 0 Delinquent Behavior ❑ ❑ ❑ ❑ ❑ 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 ❑ 0 Eating Problems ❑ ❑ 0 ❑ 0 0 ❑ Boundary Issues ❑ 0 0 0 0 ❑ 0 Requires Night Care ❑ ❑ 0 ❑ ❑ 0 0 Education ❑ 0 0 0 ❑ 0 ❑ Involvement with Child's Family ❑ 0 ❑ ❑ 0 ❑ 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) E 0 El ❑ l''/z ❑ 2 El 2%z Ill III 1/2 6 Weld County SS-23A Addendum a (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE : 3a' h}ltiiittivA 4^syvy , rIr tin,l x r <ir 4 1 a r& k x ',..z . . }� s ` t �' i I' �* , �a� t m� ,.,.sue ,� �� "k �. 'ar=,, r b' F P t' ,,,.a ` „y.g0'`' �1< ��$ i,t � >. hta g, "u' m'I`' .. y i t CVs 7,'"acC,{°k ° x . " -ax'" §� $r ate. ivyw ,a c ai:„„�geyy it { �` � ' a m rk' .. 4...i+ti,i 1- !4 tAti '. §h`'..,?4,•,: .�.,.7..,..:, 3�a.....:..eat ..',;< ........ ....s+. { Age 0-10...$16.32 r ;, 14:CU ($496) Basic Maint $4.93 day/$15omo . Level 0 $0 (� County 14;:i4 Age 11-14...$18.05 . Therapy not needed or provided �"tyg) ,t M; Basic ($549) . i', No crisis intervention, Minimal CPA by °� Level 0...$0 Maint. Age 15-21...$19.27 't (None) ($586) involvement,one face-to-face visit Liji, another source,i.e.mental health. ' MPii +$.66 Respite Care L" k, ,` y ($20) with child per month. iP lieL = $19.73 - Level 1 $8.22 day/$250 mo t, Level 1 $4.93/$150 mo +$.66 Respite Care y ' , 1 p - Minimal crisis intervention as needed, Regularly scheduled therapy ,:, one face-to-face visit per month with w=+ ,f Level 1 ...$2.99 ,� ($20.39 day/$620 mo) child, m,. up to 4 hours/month. : i, 2-3 contacts per month � +_' , -5s $23.01 ;a e 1 1/2 +$.66 Respite Care s'"1 Level 1 1/2 $9.86 day/$300 mo x" ----- -------------- ia ($23.67 day/$720 mo) „ $26.30 4. Level 2 $11.51 day/$350 mo v,,; Level 2 $9.86/$300 mo liti 2Fat +$.66 Respite Care l Occasional crisis intervention as needed, Weekly scheduled therapy, :,, imi ,t ' Level 2..$4.47 to ($26.96 day/$820 mo) fi,' two face-to-face visits with child �' is 5-8 hours a month with 4 hours of ��i 2-3 contacts per month fifl°i S+.,.k group therapy. $29.59 Rr! `-' 2 1/2 +$.66 Respite Care ,ix- Level 2 1/2 r $13.15 day/$400 mo + °i ($30.25 day/$920 mo) y., ` : ir4s • ., $32.88 Level 3 $14Oa IsLif, .79 day/$450 mo Level 3 $14.79/$450 mo r,•,,,-";° VI +$.66 Respite Care litM Ongoing crisis intervention as needed, 'plf. Regularly scheduled weekly 3 r, multiple sessions,can include Wicci i 1,t weekly face-to-face visits with child tj more • Level 3..$6.02 ($33.54day/$1020 mo) 1 i < WI iiiii pi" and intensive coordination of :::...4.: 1 than 1 person, i.e.family therapy, multiilrple services. at .4x. for 9-12 hours/monthly :;,,,:c41. 'till $36.16 m 3 1/2 prT +$.66 Respite Care a Level 3 1/2 $16.44 day/$500 mo .r ($36.82 day/$1,120 mo) . 1 044 no $39.45 a-. Level 4 $18.08 day/$550 mo n I Level 4 $14.79/$450 me }t;` 44 f iii +$.66 Respite Care 4 Ongoing crisis intervention as needed :..T.r,.. scheduled weekly _ 4 .. a* s multiple sessions,can include TRCCF .2;#1 which includes high level of case more Level 4....Neg. Drop Down i :# . a ($40.11 day/$1220 mo) a management and CPA involvement with than 1 person, i.e.family therapy, 9 SH child and provider and 2-3 face-to-face ` for 9-12 hours/monthly. E''''.• ,� contacts •er week minimum. ,.,...1'.,.,...1'. vilg Assess/ i.g,I Mil pie Emergency $30.25 day/$920 mo $13.15 day/$400 mo Level (Includes Respite) ;:z Rate =r,.yf. Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum 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 S((,ate OF THE WELD COUNTY !. DEPARTMENT OF HUMAN SERVICES 1161 By: / 11 , . i_�: .�.� �; r" � j�l By: oyAn __ Depu t!lerk to the Boalt 2 4ti Chair Signature Proton; Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT Kids Crossing OF HUMAN SERVICES 1440 E Fountain Blvd Colorado Springs, CO 80910-3502 By: _ By: / ( :t /7/i/, C ity Dire tors Sig ure/D t Contractors Signature/Date 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Kids Resource Network of Colorado Springs and Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this 17 day of v ( , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of�th 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#1508602. 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 1. 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 p'1©/q-ene Weld County SS-23A Addendum 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 2 Weld County SS-23A Addendum 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: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX TRAILS CASE ID IDOB M F WORKER COMPLETING ASSESSMENT IFIHN IRATE OF ASSESSMENT AGENCY NAME PROVIDER NAME I 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 01)One round trip a week ❑1'/x)2 round trips a week O2)3-4 round trips a week. ❑2%:)5 round trips a week O3)6 round trips a week ❑3%)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? O Basic Maint.)No participation required 01)Once a month ❑1%)Two times month ❑2)Three times a month ❑2%:)Once a week O3)Two times a week O3%)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 or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a''/3 hour per day 01%) 1/2 hour a day ❑2) I hour a day ❑2 %) 1'/:-2 hours per day O3)2'/,-3 hours per day O3%)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? ❑ Basic Maint.)No special involvement needed 01) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 11 to 14 hours per week ❑ 3)Constant basis during awake hours ❑3%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical, and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week O2)8 to 10 hours per week O2%) II to 15 hours per week ❑3) 16 to 20 per week O3%)21 or more hours per week 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.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%z)Face-to-face contact one time per month with child and occasional crisis intervention. ❑2)Face-to-face contact two times per month with child and occasional crisis intervention. E2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T I. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) 01) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensitx of conditions which create the need for services that a..1 toi this child. f, Y ryr t tEr sh "''• s .4 :. - '�"4 .ih .emu y,e nr. +. xt. ` t"�x< � x � }va. }� �r �. . +�.- R�:�' ' `'t 71 i 1� . � x+� t'e}w^ r w °� n4IffiaMl '& w l"e E, w' 33.,: r6')s ':ni. e *! iz `x rr ,�r : 5 x,..'*' : f' i. 0' Of.e. "7`e ,3 ,.o- ^, ?'t:s are r :114. ,e..� 1 'I I R` ZI,:t;tiPi ' i of + v u ka 'ua d .z s 'S '.3k (,q t �s r t� s :I a,. Via' 3L. .. .� n'm u ,y *.,.:it ,�1...xi... „a; . t#a*,.ae...:��.. . ..t�':�. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ 0 ❑ Destructive of Property/Fire Setting ❑ 0 0 0 0 0 ❑ Stealing ❑ 0 0 ❑ 0 0 0 Self-injurious Behavior ❑ 0 0 ❑ 0 0 0 Substance Abuse ❑ 0 0 ❑ 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ D ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ 0 0 ❑ ❑ ❑ Runaway ❑ ❑ 0 ❑ 0 ❑ ❑ Sexual Offenses ❑ ❑ ❑ 0 0 0 0 5 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS ' NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. rr41 '47 x:: sil+5 ' win, �' , s v.. t e .1, , ? s' r ,x+11 ' f n i ,4x t.1 (�t,.#. b w trartzfieti'e •— . E. :fit i a ,. . .. . r,- .:i a`: SkocIrtr. a' •$ ; .... a y�, ii yiy.Ac vie 2' + '�' svv+p�gibq Ia "" • &'` a S ,.xt s".>; - a t i § a rm�t.a l.. ,t: ir's "x � ,,,r � a ' .. ."- a'.ad§'3�zi*u'�'.' i,:"4' ii"in'a4uF.-�''M.IF i w.0 4:::1fa. aa. '�,ia ..'x6`:.�''`s,,,,.,. ,"+ . ' Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", 0 0 0 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems O 0 0 0 0 0 0 Boundary Issues ❑ ❑ 0 0 0 ❑ ❑ Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑I ❑ 1'h ❑ 2 ❑ 2'A ❑ 3 ❑ 3'/s 6 Weld County SS-23A Addendum • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE k@'S x Rti#.b�x ''e ra r7.17,,,r yk :3( ';1a •�P.5 ;; , ty t e G I"m✓ I;;;..,4';;,`,,`: a1` c a, ' s a'v x4' rr w w ur r •s ,. tti v :f. a d"," r,?o F R S,+ �. r 't"� •a' 1 4T U4 w ' Wt.;+.!' � .!es3 w.W "1f3 'a �.M14� 54$' � s !':,.. .,!.;,..,:c,.-.,..,„..-..::,..,:.: • 4 , I Age 0-10...$1B32 W ii.11.? ($496) Basic Maint $4.93 day/$150mo ' )k Level 0 $0 County Age 11-14...$18.05 Therapy not needed or provided : Basic ($549) No crisis intervention,Minimal CPA by .4 Level 0...$0 MaintOA Age 15-21...$19.27 (Nye $ (None) ($586) ` involvement,one face-to-face visit another source, i.e.mental health. P,1, +$.66 Respite Care s: 4,4 ($20) with child per month. t , $19.73 Level 1 $8.22 day/$250 mo u.,`t Level 1 $4.93/$150 mo „J.. +$.66 Respite Care Minimal crisis intervention as needed r Regularly scheduled therapy, f 1 one face-to-face visit per month with ' ii.' Level 1 ...$2.99 ($20.39 day/$620 mo) child, p; up to 4 hours/month. 2-3 contacts per month •t,.e $23.01 R,44t 1 112 +$.66 Respite Care .�.a'��$ Level 1 1/2 $9.86 day/$300 mo ( --------- ($23.67 , > ----------- -------- day/$720 mo) ;? i' RI Si gribt $26.30 Oft Level 2 $11.51 day/$350 mo "t1 Level 2 $9.86/$300 mo a 2 +$.66 Respite Care . Occasional crisis intervention as needed, u Weekly scheduled therapy, k k ,. Level 2..$4.47 iiig ($26.96 day/$820 mo) two face-to-face visits with child, a 5-8 hours a month with 4 hours of BO iliaKiN.I 2-3 contacts per month i y-. group therapy. .:,:7 $29.59 kw, 2 1/2 Y, +$.66 Respite Care 1 :. .: Level 2 1/2 $13.15 day/$400 mo ,i,..0 ' t ($30.25 day/$920 mo) x.in OP. $32.88 Level 3.. $14.79 day/$450 mo 5 Level 3 $14.79/$450 mo c .144 ar +$.66 Respite Care 1107 Ongoing crisis intervention as needed, .$ Regularly scheduled weekly cc L multiple sessions,can include i. 3 %,,,, ;446 Level 3..$6.02 weekly face-to-face visits with child, more ($33.54day/$1020 mo) and intensive coordination of 7 ,than 1 person, i.e.family therapy, ,,1 Et: otto multiple services. for 9-12 hours/monthly. cux 2',,c, $36.16 fork :, 3 112 +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo --------- iire ($36.82 day/$1,120 mo) 4i g.4: ..R $39.45 Level 4 $18.08 day/$550 mo p'. y Level 4 $14.79/$450 mo +$.66 Respite Care Ongoing crisis intervention as needed, a Regularly scheduled weekly ?` multiple sessions,can include TRCCF t: which includes high level of case .w? more ?• Level 4....Neg. Drop Down1st ($40.11 day/$1220 mo) +management and CPA involvement with than 1 person, i.e.family therapy, r NSW .1 OM child and provider and 2-3 face-to-face k°s for 9-12 hours/monthly. c= tiM , tiri :44. t'1. 4444 contacts •er week minimum. /.a^. p Assess/ IV Emergency $30.25 day/$920 mo $13.15 day/$400 mo s+ •;1N ------ Level `: (Includes Respite) I r'nl Rate �y{.: Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum . ~ 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 e DEPARTMENT OF HUMAN +d '� SERVICES 432 By: By: CA-r(-62 ?"-- Deput clerk to the Bo�� f/- WC Chair Signature Proton, Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT Kids Resource Network OF HUMAN SERVICES of Colorado Springs 6285 Leham Dr., Suite 101 Colorado Springs, CO 80918 • By: By iabTald � �1 C ty D(ire tor's nature ate -Contractor's Signature/Date �I( / aoia-aso? 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the"Agreement") between Lutheran Family Services Rocky Mountains and Weld County Department of Human Services for the period from July 1,2012 through June 30,2013. h The following provisions, made this j day of ,2012, are added to the referenced Agreement. Except as modified hereby, all terms o th greement 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#45080. 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 I1. 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 1 Weld County SS-23A Addendum • 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 2 Weld County SS-23A Addendum 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: 3 Weld County SS-23A Addendum • • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX ['RAILS CASE ID 'DOB M F I I WORKER COMPLETING ASSESSMENT rHq 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 ❑1)One round trip a week ❑1%)2 round trips a week 02)3-4 round trips a week. ❑2%:)5 round trips a week 03)6 round trips a week ❑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 01)Once a month ❑1'/:)Two times month 02)Three times a month ❑2''/)Once a week 03)Two times a week 03%)Three times a week or more P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a%:hour per day O1./z) %,hour a day 02) 1 hour a day 02'/3) I%:-2 hours per day ❑3)2'%-3 hours per day ❑3'/i)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? ❑ Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week OM 5 to 7 hours per week 02)8 to 10 hours per week ❑2'/z) I 1 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 age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? O Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week O1%)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%:)21 or more hours per week A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/)Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'h) Face-to-face contact three times per month with child and occasional crisis intervention_. ❑3)Face-to-face contact weekly with child and occasional crisis intervention. ❑3%:)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e.Medicaid) DI)Less than 4 hours per month 02)4-8 hours per month 03)9-12 hours per month 4 Weld County SS-23A Addendum (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. 4.i t Raiingof Condition ` ',�`:• �e(+''��'''' •' ' I�I ' t `1 ti r 4,�,(;{ �j�l�1}.<<. (Check one box for each ca '' `i+l�'•l } ! ?'I i"). r r, I• ' • MV, e,. w...,..;radix;. AstesSmentA1ieas t> • oderatei t ''' r .: ,s!'irt i' . . .; t,....:'.. but mad Moderalci Moderate s ;Hiii 8i •S•�' I�!' !'.'-f+.i:7 '„�! 112 2 1/2 •:0, ''r' Li,1. rat. 'G, i. t:` ,;;1. Aggression/Cruelty to Animals D D ❑ D ❑ D D Verbal or Physical Threatening D O 0 0 0 0 0 Destructive of Property/Fire Setting O O O O ❑ O U Stealing ❑ O O O O O O Self-injurious Behavior O O O O O ❑ O Substance Abuse D O O O O O O Presence of Psychiatric Symptoms/Conditions ❑ ❑ O 0 0 0 0 Enuresis/Encopresis ❑ O O O O ❑ O Runaway O O ❑ O El O O Sexual Offenses O O O O ❑ O O 5 Weld County SS-23A Addendum • (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 ;4 l" ii, (Check one box for each category) ti, -'1i:„I :'41. s 7 s,. 'fir 3�t" ��:•. Assessment Areas Mid toderstel 'q'' &Re NU Moderates I41oderrttp ' ' 'Compnfnia 0 1 1 1/2 2 21/2 3 31/.2 Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ ❑ O O El O O Delinquent Behavior ❑ ❑ ❑ ❑ O O O Depressive-like Behavior O O O O O ❑ O Medical Needs (If condition is rated"severe", please complete the Medically O O O O O O O fragile NBC) Emancipation O ❑ ❑ O O O O Eating Problems ❑ O O O ❑ O O Boundary Issues O O O O O O O Requires Night Care ❑ O O O O O O Education O O O O O O O Involvement with Child's Family O O ❑ O O O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) fl 0 [l1 n I'/z ❑ 2 O 2'/2 ❑ 3 O 3'/z 6 Weld County SS-23A Addendum (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE RECOMMENDED RECOMMENDED AGENCY RATE I , LEVEL i • �r, �� r a OF • ,pi,t a r PROVIDER RATE Imams SERVICE i" ! 1'i ''�",Ii :T..r, •• ,iii,i'iil li it l ,+r dEnio. P1-P6• — 'Al • •• .,.1i1 : ,{; It 1,.,L , il;it . , Level Rate Case Management Thewapy : • l'11 IiEli' ' ..i 'tl ' (Admin.Malnt.) (Admin-Services) ..• ` 1 Age 0-10...$16.32 ($496) Basic Maint...... .........$4.93 day/$150mo Level 0 $0 Age 11-14...$18.05 County Therapy not needed or provided Basic ($549) No crisis intervention,Minimal CPA by Level 0...$0 Maint. Age 15-21...519.27 • (None) ($586) involvement,one face-to-face visit another source, i.e.mental health. +$.66 Respite Care ($20) with child per month. $19.73 Level 1 $8.22 day/$250 mo Level 1 $4.93/5150 mo 1 +$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy, one face-to-face visit per month with Level 1 ...$2.99 ($20.39 day/$620 ma) 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 --- __ il,, _—_ _ ___ ($23.67 day/$720 mo) $26.30 Level 2 $11.51 day/5350 mo Level 2 $9.86/$300 mo 2 +$.66 Respite Care Occasional crisis intervention as needed, ,' Weekly scheduled therapy. Level 2..$4.47 ($26.96 day/$820 mo) two face-to-face visits with child, 5-8 hours a month with 4 hours of 2-3 contacts per month group therapy. I''' $29 59 . ` 2 1/2 +$.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..$6.02 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/$450 mo r. +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly 4 multiple sessions,can include TRCCF which includes high level of case more Level 4....Neg. Drop Down management and CPA involvement with ' than 1person, i.e.family ($40.11 day/$1220 mo) ' g therapy, child and provider and 2-3 face-to-face for 9-12 hours/monthly. contacts per week minimum. Assess/ Emergency $30.25 day/$920 mo $13.15 day/$400 mo Level (Includes Respite) "'--— ---— -- Rate Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum 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 Boar WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF �°�° 2 OF THE WELD COUNTY '-.5 . ,i � DEPARTMENT OF HUMAN Iiii � SERVICES By: % A '� By: Z_____., Deputy erk to the Board Chair Signature Prvtem AUG 292012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Lutheran Family Services Rocky Mountains b, 5. thrietki OF HUMAN SERVICES 2032 Lowe Street, Suite 200- a)1 r{.2-Cl 'Pert-erittinsTeCr8r1525— WIA-P.A, CO 871.-- • By: ‘C y ire tor's l ature/D a Contractor's Signature/Date ' „j/p cA,tm NZ Xt-ik l-tdS8-(1441-- 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM `s To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Maple Star Colorado and Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this 3 day of liva, 2012, are added to the reference' Agreement. Except as modified hereby, all terms of�ement 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#90967. 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 c2,0/9 023e, Weld County SS-23A Addendum 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 2 Weld County SS-23A Addendum • 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: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE 1D# SEX TR[ AILS CASE ID IDOB F WORKER COMPLETING ASSESSMENT 1FIH# I rATE OF ASSESSMENT AGENCY NAME PROVIDER NAME I 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 ❑1)One round trip a week ❑1''/)2 round trips a week O2)3-4 round trips a week. ❑2''/)5 round trips a week O3)6 round trips a week O3%)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? O Basic Maint.)No participation required DI)Once a month 01%)Two times month O2)Three times a month O2%)Once a week ❑3)Two times a week O3%)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 or special education plan? ❑ Basic Maint.)No educational requirements ❑t)Less than a%hour per day 01%) 1/2 hour a day O2) 1 hour a day O2 %) I'%-2 hours per day ❑3)2'A-3 hours per day ❑3Y)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? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) 11 to 14 hours per week ❑3)Constant basis during awake hours O3%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical, and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week O2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week O3%)21 or more hours per week 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.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..I to this child.., _ " �# t z x�" F ":444:47'.451,4..;ic 0 5 ,iii' x+,y s"h�,4M ^, x Y 4 n i l; in vii i 3 � m is `y { i F u e r s . .l- '1"- t'k i i r.,a 9 "3 xi. % 3x ll { "�'. . � m:):" '"' mot, ,£ ,' F ra"�xt�` � y • )5„ ?p t a;# E o- 9 42..;;;?`..? �' ;ttwry s r } 1 ;a. +ty..a A'8, -a a iM t a�di‘x 14'4 Sari.444 sits � '1,4� t::,',"‘"' +a '.'.„. j ,' X4,1 �.` °�, r v t," f.Y s.t '�" p s '"- ;: " l s d 3 x 'j ' . . YGk ik�:w .:.,. �Gh''�.�'w� �,a�''Ji�.:,-�' Y�'��"!s � � ms ili sa. f. v • +. Aggression/Cruelty to Animals 0 0 0 ❑ 0 El 0 Verbal or Physical Threatening El 0 0 ❑ ❑ 0 ❑ Destructive of Property/Fire Setting 0 0 El ❑ 0 El ❑ Stealing ❑ 0 ❑ El El 0 0 Self-injurious Behavior ❑ ❑ 0 El 0 0 ❑ Substance Abuse ❑ 0 El 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 ❑ ❑ 0 El Enuresis/Encopresis ❑ ❑ ❑ El 0 El ❑ Runaway ❑ ❑ 0 0 ❑ El El Sexual Offenses ❑ ❑ ❑ El 0 ❑ ❑ 5 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. u'. s say '�s 4.E.3ggr '"'a � v a"d' 'y ti *+�s � y=N "-r44'4'.4 i �'t i'.13...12.41.4 3x " " z: A .' ,�Y "4+ f "1 f e —II h tI.sx*.ts ".d 1vvf ct &? '' �s x' & r' ,, `' ., r�t Ymtu 4.. ..zf f d - w ,.i a *.1r s, + r f t C ,j F ,-,..s.=-..',..t.;i d � � a r}# . 'I M .t d Inappropriate Sexual Behavior ❑ 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", 0 0 ❑ 0 ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 0 ❑ 0 ❑ Involvement with Child's Family 0 0 0 0 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 El ❑ 1'h ❑ 2 ❑ 21 ❑ 3 ❑ 3% 6 Weld County SS-23A Addendum p • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE �' 5 #'u ,ks'ri' su S'Y "C.'�4'�"'y# apty v"n.*' r 'I ".g,'I . +`�+'y r :4a( 1 IT s.'N. T4 iCI;r ye : " a 'I ian 5 t'• .� ' '+,.. ` r #+S i 13 T" i ,L 11 s4 P „1. P it i Y . .j - ;p - o 4:1 4 i 1, N A ;':y4°49� 4 F k i ,5. 9 :4 itN:F in f i 'ta 4 1 t ,'f „ $ .p .. �i 9 x a °k' e3*eft c e+ ''t • r w. 4 .: .,..u1 a :7 1 a id fir.'t ;f( 'i ° i s. S IExi t a$14. �� !k`tT5L.j �a�: h Y1` en '�. y • p t 4%x L)h Pk, °etn 3a#, 1,t x sc r, e R ;'t;'f�,"'E sue ;i•Wx *z� x•- ` , ,. a!n 3 1a. L 1# "i '°� { '. .711 r t' . e 0'9` i,Ci "rj a`� ilt z P M" a i :,,I i F mgi,,i trail + �r� ,>>��.,r`s'�,°,i .�a't6�u.. .. � ? # 4um?°Lr " .saR:�aR#•�'a,�a =s" Age 0-10. $16.32 :' r�,. " ON ($496) Basic Maint $4.93 day/$150mo Level 0 $0 ,, e Age 11-14...$18.05 ii ° ii County N• Therapy not needed or provided Basic '`"( ($549) No crisis intervention,Minimal CPA by Level 0...$0 • Age 15-21_.$19.27 z Maint. (None) Igo ($586) _ involvement,one face-to-face visit another source, i.e.mental health. 5" +$.66 Respite Care i)o- O a ore' ., ($20) Ki with child per month. 0= a'-,'s op $19.73 Level 1 $8.22 day/$250 mo . Level 1 $4.93/$150 mo ' u 1 +$,66 Respite Care Minimal crisis intervention as needed y Regularly scheduled therapy Zil one face-to-face visit per month with d iIIS Level 1 ...$2.99 ($20.39 day/$620 mo) child, up to 4 hours/month. z -`E 2-3 contacts per mouthv"Iy' rtIfii $23.01 r. tt 1 1/2R4 .:,,„..!,. +$.66 Respite Care y Level 1 1/2 $9.86 day/$300 mo g '. 224,4 ($23.67 day/$720 mo) ;'4i $26.30IAA ft. Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 moiM 2 +$iita, .66 Respite Care Occasional crisis intervention as needed t ; Weekly scheduled therapy, iiy.; :*:, liv. Level 2..$4.47 liA ($26.96 day/$820 mo) two face-to-face visits with child, 5-8 hours a month with 4 hours of ;r: Diril n• 2-3 contacts per month 4 22 group therapy. a i' $29.59 P I ( `; 2 1/2 +$.66 Respite Care Level 2 1/2.........$13.15 day/$400 mo Oil --- viii ($30.25 day/$920 mo) ° F„ firg $32.88 Level 3 $14.79 day/$450 mo , Level 3 $14.79/$450 mo rtiz Imli +$.66 Respite Care Ongoing crisis intervention as needed, s Regularly scheduled weekly 4Pih" . 3 11 multiple sessions,can include Level 3..$6.02 itp, weekly face-to-face visits with child, more 5'1 I ($33.54day/$1020 mo) ya r. and intensive coordination of a than 1 person, i.e.family therapy, g af fel multiple services. .x„ for 9-12 hours/monthly. $36.16 �' 3 1/2 +$.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo " iii ($36.82 day/$1,120 mo)t, Nit t`.._ '' $39.45 Level 4 di $18.08 day/$550 mo Level 4 $14.79/$450 mo r°y ,is +$.66 Respite Care Ongoing crisis intervention as needed x1 Regularly scheduled weekly 'r Ti.„, 4 ,.�4 multiple sessions,can include i TRCCF : which includes high level of case ,' morek.tai Level 4....Neg. Drop Down ti - to ($40.11 day/$1220 mo) management and CPA involvement with 1.,R than 1 person,i.e.family therapy, ikl IN child and provider and 2-3 face-to-face 0 for 9-12 hours/monthly. til.ii . .,OA contacts .er week minimum t,:,k -1.• Assess/ ' ,ail AgN }„ Emergency $30.25 day/$920 mo ETI Level (Includes Respite) $13.15 day/$400 mo41 F Rate cik ab Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum • • 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 ita• s La\ OF THE WELD COUNTY z3-en p atii DEPARTMENT OF HUMAN ri R 5t.� SERVICES iaet tita By:� • %.M " Deputy erk to the Boar. a3/4, Chair ignature Protein Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT Maple Star Colorado OF HUMAN SERVICES 2250 S Oneida Street, Suite 100 Denver, CO 80224-2557 By: r Byt►y; `G WILY '7" 31 -/ ty Dir tors i natur / ate Contracto s S nature/Date C/ode -0,186 ; 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between New Start Youth Services LLC and Weld County Department of Human Services for the period from July 1,2012 through June 30, 2013. The following provisions, made this 3 day of , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of t e 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 1Di/1528224. 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 cma-a 3 Weld County SS-23A Addendum 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 2 Weld County SS-23A Addendum 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: 3 Weld County SS-23A Addendum • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX F TRAILS CASE ID DOB I WORKER COMPLETING ASSESSMENT HH# �M I IDOB 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 DI)One round trip a week O11/2)2 round trips a week O2)3-4 round trips a week. ❑2'/:)5 round trips a week ❑3)6 round trips a week O3%)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 ❑1'/:)Two times month O2)Three times a month ❑2''/)Once a week O3)Two times a week O3%)Three times a week or more P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements DI)Less than a''/x hour per day O11/4) 1/4 hour a day O2) 1 hour a day O2 %) 1'h-2 hours per day ❑3)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? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1%)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 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 age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/x) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%)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.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. Di 1/4)Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0)Not needed or provided by another source(i.e. Medicaid) DI)Less than 4 hours per month O2)4-8 hours per month O3)9-12 hours per month 4 Weld County SS-23A Addendun • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE • BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. ` a Aid ` t 1 i v E s vi Y v ....� Inte , �� ka t a "K`i$ vw k`h o 5 �'4.,;t0 ``b4i.x . "i n-! ,3�. cl 7 t �w�r�tt� a T� ..j. � • �J�� .• .} ?,�� 'bltifke; 9i1 " t [. of �.-s.. . tV.p. y. y.y 3j'} �"� �It>£ ig t g'},,:.;,s.,,,,. e 1 y r t':e w. aau a t r y.'> . r x Aggression/Cruelty to Animals ❑ ❑ 0 0 ❑ ❑ 0 Verbal or Physical Threatening 0 ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ 0 0 0 0 0 Stealing ❑ ❑ ❑ 0 0 ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse El ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑ Cl 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ 0 Runaway ❑ ❑ ❑ ❑ 0 ❑ 0 Sexual Offenses ❑ ❑ ❑ ❑ 0 ❑ 0 5 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS • • BEHAVIORNEEDS ASSESSBASEDMENT CONTINUED Please rate the behaviodintensit,{ of conditions which create the need for services that a..I to this child. .f� 3/x vt havi 't' ,t, 's a� S r..3.' tr 3gai, - ii „met t :.,. , "iS -rpm: ' ii t szt saig 3r s r g' 1 . . . i i�;�:::':v t � ' 91G&` �a: 4 fd ' ` pia s'.,'.-7y,..3-; � ° % ..i :�.� m n s�.r a .� u xx. i u � ¢ t', ' si Ate. � � r 47- </4,,,,-;-q, . \' kY. `3 sil .'.3 ' i Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ 0 0 Disruptive Behavior ❑ ❑ 0 0 0 ❑ 0 Delinquent Behavior ❑ 0 0 ❑ 0 0 0 Depressive-like Behavior ❑ ❑ ❑ 0 ❑ 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ 0 0 ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 ❑ 0 Eating Problems ❑ 0 0 ❑ 0 0 ❑ Boundary Issues ❑ 0 0 0 ❑ 0 0 Requires Night Care ❑ ❑ 0 ❑ ❑ ❑ 0 Education ❑ ❑ ❑ 0 0 ❑ ❑ Involvement with Child's Family 0 ❑ 0 0 ❑ 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 El 1% Ill 2 El 21/4 ❑ 3 ❑ 31/2 6 Weld County SS-23A Addendum r • • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE i. �aF4 'b! a' K'"� ".0 ',4;,s'.,c�' z 1 v +'r to iT _+, x".h x 0'n i ITa° hs i5 "• t :1311 9 ' k.5s,,{� r ti v r 0 �.�„,� a�: sa,s` e s'at .n ' ° „ ew'..th utis * :S . ₹ ,,.!, ,,,,„_6 x_,._..ww`i°.r"t,f Y:,.:.r x v,r : ..ryes.,;.,-...,.. Age 0-10...$16.32 tom, V`'y ;t' sat. ($496) ' Basic Maint $4.93 day/$150mo Level 0 $0 County Age 11-14...$18.05 , . Therapy not needed or provided ;, :r Basic ($549) No crisis intervention, Minimal CPA by k Level 0...$0 Mamt Age 15-21...$19.27 = $P1 Xyt (None) il, ($586) involvement,one face-to-face visit another source, i.e.mental health. `t o +$.66 Respite Care I`�- ' L ($20) Tt with child per month. Vz ° .. $19.73 FT7Level 1 $8.22 day/$250 mo AI Level 1 $4.93/$150 mo a ° +$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy, �8 1 - ,V Level 1 ...$2.99 ., one face-to-face visit per month with ($20.39 day/$620 mo) child, : up to 4 hours/month. LP:(! x 2-3 contacts per month c,;;_ $23.01 $ " :4:78No 1 1/2 i4.,g +$.66 Respite Care . . Level 1 1/2 $9.86 day/$300 mo "t ------------------ '-..,4;:2 ---------- ($23.67 day/$720 mo) 4 r"'+, �m $26.30 K Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo 41 .r. +$.66 Respite Care a ix Occasional crisis intervention as needed, Weekly scheduled therapy, ? 2 } ,� t; Level 2..$4.47 k ($26.96 day/$820 mo) ' two face-to-face visits with child, s, 5-8 hours a month with 4 hours of kg h 2-3 contacts per month ,,t;(8group therapy. 3z=; h $29.59 a§+ a .� 2 1/2 9. 4.66 Respite Care ,,,,;#:. Level 2 1/2 $13.15 day/$400 mo ($30.25 day/$920 mo) n'- ez; :citri 1 $32.88 Level 3 $14.79 day/$450 mo k o Level 3 $14.79/$450 mo `'.1 +$.66 Respite Care Pa. Ongoing crisis intervention as needed, Regularly scheduled weekly 4 3e multiple sessions,can include Level 3..$6.02 P weekly face-to-face visits with child, more i ,- ($33.54day/$1020 mo) ,,43 and intensive coordination of than 1 person,i.e.family therapy,1: pti'`,ta multiple services. for 9-12 hours/monthly. t $ l? $36.1600, 3 1/2 fir. 4.66 Respite Care Level 3 1/2 $16.44 day/$500 mo �n ------- I' ($36.82 day/$1,120 mo) till"'r-. s M M. ,t '. . $39.45 .= Level 4 $18.08 day/$550 mo p Level 4 $14.79/$450 mo n r +$.66 Respite Care 1.4.1k Ongoing crisis intervention as needed i Regularly scheduled weekly ili ,• _ `- y, 4 multiple sessions,can include ti TRCCF 1i which includes high level of case ' more s Level 4....Neg. Drop Down k,, management and CPA involvement with 0 1 than 1 person, i.e.family therapy, €'°tii "#,g y , ($40.11 day/$1220 mo) , 9 n ' child and provider and 2-3 face-to face for 9-12 hours/monthly. KO tr. t1 -� 4'i~ contacts •er week minimum. _k' 1,:4, Assess/ ;` Emergency Pi $30.25 day/$920 mo �' =,'.77!!Ni -_----_— $13.15 day/$400 mo Level 5'= (Includes Respite) ^d Rate ar I. ' - t- *. Ii Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month Weld County SS-23A Addendw 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 /� 1Le � OF THE WELD COUNTY y „ c ,� DEPARTMENT OF HUMAN kl2 SERVICES aw By: Ld%/iii i �� .� ii�. � \ By: Deputy 'erk to the Boars� � Chair Signature Protein Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEW START YOUTH SERVICES P O BOX 1392 PUEBLO, COLORADO 81002 By: By: r I xm-eEKiL &*C Co Direct is Si atur ate Contractor's Signature/Date ao/a-L73O 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Parker Personal Care Homes Inc. and Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this 3 day of / .A;cc,/ , 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#1512100. 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 g&/a—e2S j 1 Weld Cnnnty CS-71A AddnnA„m 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 2 Weld County CC-71A ea,tna..... 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: 3 Weld County SS-21A Addendum (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX I TRAILS CASE ID �OB MF WORKER COMPLETING ASSESSMENT �HIIriftIRATE OF ASSESSMENT AGENCY NAME PROVIDER NAME I 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 DI)One round trip a week ❑1%:)2 round trips a week O2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week ❑3'/' 7 round trips or more 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 ❑l)Once a month ❑1'/z)Two times month O2)Three times a month ❑2%z)Once a week O3)Two times a week O3%)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 or special education plan? O Basic Maint.)No educational requirements DI)Less than a %z hour per day ❑1'/z) '/,hour a day ❑2) I hour a day O2 %) 1'/z-2 hours per day ❑3)2%z-3 hours per day ❑3%z) 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? ❑ Basic Maint.)No special involvement needed ❑I)Less than 5 hours per week O11/2)5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) 11 to 14 hours per week ❑3)Constant basis during awake hours O3%)Nighttime hours 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week O11/2)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%z) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week 1. How often is CPA/County case management required?(Does not include therapy) ['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) Di) Face-to-face contact one time per month with child and minimal crisis intervention. O11/2) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. ❑3)Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. 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 n (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..l:it:: child. '� J ftw t o +f tt a t y .L br} y+'o i S Y i v c ti a 9,yyKY` V + n t rot x, ,, f"ki . 1 ! . .4 Z e r t''k . t `"� y .d & a}.t + H �yk'-z 3� S k$' anx`•3y tt "" dy ` 't..A ' r e 'Y T {�.. it - . fir N -� o r ti4C,1)..:.54 L', L ,, i x x.� sx�.. 3 r �- L•'''it i',1- ' u 4i a ua. ' 'ay} EFa �' [17` yi :: ' `ri5 ' S,+A �y ` .,r* V. r ri x ""1 ,3r ` •k*•!:44144(+ r +* .° '' '''r , i r' a 'j s5 It 3*'� se.a�'bd"t °^ �4 Pz`:'-t" l n< wF aA '�v ,,,/-10, Aggression/Cruelty to Animals O O O O O O O Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting O O O O O O O Stealing ❑ O O O O O O Self-injurious Behavior ❑ O O O O O O Substance Abuse ❑ O O O O O O 'resence of Psychiatric Symptoms/Conditions ❑ O O O O O O ?nuresis/Encopresis ❑ O O O O O O tunaway ❑ O O O O O O 'texual Offenses ❑ ❑ O O O O O 5 Weld County SS-23A Addendum (Exhibit B) ' WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a.0 to this child. Ew,A .r isj ^P*f E` ''t §$ '�y1, .!; i<.: xf , t 1x4 v&d :.It.. , s a t" ' s `),,, a is i vs c .r„t. i r ' t )�lr dta;tZ v .' "3G'' , + ;; 33A .:;,',4-A.:,-.4'e wd'. ry f " E �"-s�`�" '.00014,-,4,1'` � � � t ,rn y' { 3t'a � u t� rh a ' ',,,,..s.24,:. t - 7 v, "Y'lb.`-i { �o-cYa.x - 4 1 ' ₹ €, 3wk T r?' i 'X Ht1 s t 23a4: f Y3 b 2:M it n ' Iil�ici 'f r,..t a.Y'x# , r j1+ a .N a r., ar x ' ,f v I�"!'d `,r atyv« s s t :, _„, s • fr Un ;,,,rig ;.,., "n sfi L. x`t [ ��' A ..�� "x�1�G.` �.Y� 7 'W. •2�e,,., i k�x�Y� ''tM` .r a . ci rcaz*. r ., : ¢ e: ; m ��i 6'L?i. t ... s. �'f�'8t'�� .�� 9 J ,t.%� r{a��`t M1 St s. � ; s��rt(d., L^✓�ll-.5' t„MP:t�fi SFa,t Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 ❑ 0 0 Delinquent Behavior ❑ ❑ ❑ 0 0 0 0 Depressive-like Behavior ❑ ❑ 0 ❑ ❑ 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ 0 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ 0 ❑ ❑ ❑ 0 3oundary Issues ❑ ❑ 0 0 0 ❑ 0 tequires Night Care ❑ ❑ ❑ ❑ ❑ 0 0 ?ducation ❑ 0 ❑ ❑ 0 ❑ ❑ nvolvement with Child's 'wilily ❑ ❑ ❑ ❑ ❑ 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1% ❑ 2 ❑ 212 ❑ 3 ❑ 3V2 6 Weld County SS-23A Addendum (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ..‘;'/Q. y + w v y H. Z a ' ' `cif ? ' gs 'tt rat chi-':r•-t7.7:: " r ' y. ::.'-':,../,;.,,,,,l.,--.. • ',' sP , ' ° ,.kh t� o [t'"a *9 ,,P q'" =P A�../I,-e.^ rl ', gl',...Si•i' 1.1:1:: 1:C4 C� .,�"4,4,-. d�9`Alr° »� rx " �jt'x, t �*`P L Y 7 : •Zi' ' �� ~i' r4r4V�tts„„,, ; fir x- . '`k3 1::,,,;.,74.. Age 0-10...$16.32^" r ($496) -, Basic Maint $4.93 day/$150moig Level 0 $0 :" Countt. Age 11-14...$18.05 �° Therapy not needed or provided , Basic It"' ($549) 'sy, No crisis intervention,Minimal CPA by , Level 0...$0 Maint s,^ Age 15-21...$19.27 t£, , (None) ($586) 1.4.7., involvement,one face-to-face visit ` another source, i.e.mental health. n +$.66 Respite Care z ' c�^( il` ' ($20) with child per month. c$ $19.73 Level 1 $8.22 day/$250 mo 1�' Level 1 $4.93/$150 mo +$.66 Respite Care Minimal crisis intervention as needed '1 Regularly scheduled therapy, 1 _ one face-to-face visit per month with ' .,,'-t,,, Level 1 ...$2.99 s"v ($20.39 day/$620 mo) ^:' child, up to 4 hours/month. § w 2-3 contacts per month 'r ,.,. $23.01 x.a ^., 1 1/2 +$.66 Respite Care ,.( Level 1 1/2 $9.86 day/$300 mo "L ($23.67 day/$720 mo) ».' $26.30 Level 2ll $11.51 day/$350 mo +. Level 2 $9.86/$300 mo . S 2 +$.66 Respite Care 0 Occasional crisis intervention as needed, e;.. Weekly scheduled therapy, Level 2..$4.47 ($26.96 day/$820 mo) two face-to-face visits with child, 5-8 hours a month with 4 hours of k,c, Va. `r 2-3 contacts per month group therapy. $29.59r". +: 2 1/2 a +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo ------------- -- i __--- ,, ($30.25 day/$920 mo) ... . . $32.88 pt4?,% Level 3 $14.79 day/$450 mo ., Level 3 $14.79/$450 mo ,,-,-.4- 4: , '+$.66 Respite Care Ongoing crisis intervention as needed, ti r Regularly scheduled weekly ,-*1 a ti 5- multiple sessions,can include 3 r .A Level 3..$6.02 1 weekly face-to-face visits with child, - more J."- . ($33.54day/$1020 mo) and intensive coordination of v' i than 1 person,i.e.family therapy, s� sa Rey ti h.i multiple services. 1e for 9-12 hours/monthly.gV $36.16 3 1/2 +$.66 Respite Care 44 Level 3 1/2 $16.44 day/$500 mo 7,' ----------------- . - ------- 44, E. ($36.82 day/$1,120 mo) ,. *1! $39.45 ' Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo rx m„, +$.66 Respite Care 9'' r Ongoing crisis intervention as needed rt Regularly scheduled weekly 4 kTr multiple sessions,can include which includes high level of case a more TRCCFy: �, Level 4._.Neg. Drop Down t,- t ($40.11 day/$1220 mo) , management and CPA involvement with . than 1 person,i.e.family therapy, a= , `V) child and provider and 2-3 face-to-face for 9-12 hours/monthly. ,t `v'" .Ji contacts ser week minimum. Asseess/ency , � - , $30.25 day/$920 mo ` 1' Emer Level ri (Includes Respite) ' $13.15 day/$400 mo r ---------------------- Rate 44 `3u Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum 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 S ada OF THE WELD COUNTY DEPARTMENT OF HUMAN `��t�'• SERVICES �C8 tut 2,T': "3 By: By: Deput lerk to the Board Chair y ignature Approval as to Substance: CONTRACTORIDf°m AUG 2 9 2012 WELD COUNTY DEPARTMENT Parker Personal Care Homes Inc. OF HUMAN SERVICES 5394 Marshall Street Arvada, CO 80002 BY By: C ty Dietor's S' ure/ tocactorcte1Hr2_ act/a7- a-9' 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Quality Life Services LLC and Weld county Department of Human Services for the period from 2 July 1,2012 through June 30,2013. The following provisions, made this /7 day of 0-.14 , 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#32066. 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 1. 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 c2O/2-&309 Weld County SS-23A Addendum 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 2 Weld County SS-23A Addendum 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: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX (RAILS CASE ID �OB F WORKER COMPLETING ASSESSMENT IHH# 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 DI)One round trip a week O11/2)2 round trips a week ❑2)3-4 round trips a week. O2%) 5 round trips a week O3)6 round trips a week O3%)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? 0 Basic Maint.)No participation required Dl)Once a month 01%)Two times month O2)Three times a month O2%)Once a week O3)Two times a week O3%)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 or special education plan? O Basic Maint.)No educational requirements ❑l)Less than a '/,hour per day 01%)%hour a day O2) I hour a day O2 %) 1'h-2 hours per day O3)2'/2-3 hours per day O3%)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? ❑ Basic Maint.)No special involvement needed 01) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑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 aae appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3''/)21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑I%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) DI)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. ktt, ,lry, * '1 * ,: E P'1797rr { 1 s �. i•............ x� ,$53' '": s9 ��ci : ,rz,.,'vC'a p '.. t �,�� +�. f+, Y r ij�'i�" �' .`-;.. -sfk' 4 . yr �,- v +� Y 'i. !P.I, , a9'a k 1,,,,.....a ! a vast!: '#S r. , Y ! i.� Ira �:pc E '. R .1 t'41.?/": r T r -..t.71-.4.1;t-S.,,,,,, 3 1; 4 . .. r }��`-1...�}};'"w r A, " �...:.;! e.._ vv.'nC . ! � ` xv °'�cl qs c ''�2;r$e.aw ..,....�.. -y. �a .s. Aggression/Cruelty to Animals ❑ ❑ 0 0 0 0 0 Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ 0 0 0 0 0 Self-injurious Behavior O 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis O 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 5 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. +i4 �"se`W` ,i " mtr . '.a _?t '7.65 +.Qa" 'at r§joss' •-d c ,{ , �'' ( :$+ r a# 'W° t t air¢ft. it It y°'4 �*" Jas ss V r z4.fit JK• v t§? 'x 'i . l '''; H= t, �a to ' - t a•`0 x .�f rh F 4 '" 'r x-43 'S.,:-6s pia ., *trt r E ,., .. �#st � *" a 4Y', a ,. •s � .. .'_ �kii ti .•r k;' n' '"t! 1' urrv'r*,' 'av;y i,?K: u' ., la Oh 3 :— £ x -,a 4ev'.. 't k J $ A 9 Va.` s 4 ::;I iiiirtsgitAto a"„ J e, .ct u... r t ai , f r `ESE Plki•Dit Inappropriate Sexual Behavior ❑ 0 0 0 0 0 0 Disruptive Behavior O 0 0 0 0 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ 0 0 0 Depressive-like Behavior ❑ ❑ o ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ 0 0 El ❑ 0 ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ ❑ 0 0 ❑ ❑ ❑ Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education O 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 Ell ❑ 1'h ❑ 2 ❑ 2'/a ❑ 3 ❑ 3''/ 6 Weld County SS-23A Addendurr (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE �i1,�,Lp�,,. Tpw *w: ag'"$4 r'a�az ' > o-�yx x r d v i ' r,„•a*.'c - .,*4^;'ij j ,1 -�k # < Cs,,' ft' 0.4.04 'e v C 3E.ggiC. %* 4 Y '� �f. C % '�'i Xt M">#.b'5 &ry �k ter�* i ,.t,n "F • ''�1 ' rks" . rs �ti•t .� § ' ' ^'c4 s (' «.;e ' M`�'`' w'i§`.4P t� i ;fir i t *` " 7K p ",� °` . n t .' x s ' ta. Y- " ,aYom+ {.. 4 k5 (q, � s ,t,,P.�� r ay nva ;4ti'hb 1.71wii..ak....'r e vx* ae.,utiy :i....i � �:#d:ec ! t.c.:., ..°+.r o,... + k s.. .qa ..,., -i- §{`. .> Age 0-10 $16.32 2 'r 'a ; ($496) Basic Maint $4.93 day/$150mo Level 0 $0 County ritItt Age 11-14...$18.05 Therapy not needed or provided r>Mp Basic ($549) No crisis intervention,Minimal CPA by !.Ni, Level 0...$0 Maint. Age 15-21...$19.27 ' " (None) t' ($586) " , involvement,one face-to-face visit another source,i.e.mental health. +$.66 Respite Care " �, ($20) 5' with child per month. a 11 $19.73 Level 1 $8.22 day/$250 mo Level 1 *''}a. y ra $4.93/$150 mo yr 1/. 1 +$.66 Respite Care rte; Minimal crisis intervention as needed, a Regularly scheduled therapy, 4, .:', one face-to-face visit per month with aX : Level 1 ...$2.99 child, ¢" up to 4 hours/month. ($20.39 day/$620 mo) f ''9 x 2-3 contacts per month : $23.015;." ' ₹iii 1 1/2 4.66 Respite Care Level 1 1/2 $9.86 day/$300 mo + ($23.67 day/$720 mo) 7 A ti:. $26.30 9'°' Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo 1,.v P'01 2 al +$.66 Respite Care Oil Occasional crisis intervention as needed, Weekly scheduled therapy, a tj Level 2..$4.47 ($26.96 day/$820 mo)IA j two face-to-face visits with child, 5-8 hours a month with 4 hours of 2-3 contacts per month t t" group therapy. ` $29.59 -4 Z. 2 1/2 +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo ' ($30.25 day/$920 mo) P.VP.1 we . F ` pti i tip; $32.88 , Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo p,;, FM 4.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly fii„ rtj multiple sessions,can include ' weekly face-to-face visits with child, h more s Level 3..$6.02 ($33.54day/$1020 mo) a� #,vil VI y and intensive coordination of `} than 1 person,i.e.family therapy, a i,r. multiple services. „„ for 9-12 hours/monthly. ,`,o-T` x1 $36.16 '- P* 3 1/2 +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo �^ -------- v. ($36.82 day/$1,120 mo) j.'s ry i $39.45 s Level 4 $18.08 day/$550 mo :;$ Level 4 $14.79/$450 mo r -4.66 Respite Care ` Ongoing crisis intervention as needed, , Regularly scheduled weekly a4' 4 .xs multiple sessions,can include ktp ',,' which includes hi h level of case °:' more TRCCF a=: 9 ; y, / Level 4....Neg. Drop Down management and CPA involvement with r ' than 1 person, i.e.family therapy, 5' ($40.11 day/$1220 mo) ,Fry , rial ,:= child and provider and 2-3 face-to-face lc; for 9-12 hours/monthly.PS,„�,. �; contacts per week minimum. .„" Assess( y„ 'r Emergency $30.25 day/$920 mo s $13.15 day/$400 mo Level (Includes Respite) .4,-. Rate ' '~ 24, tet Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum 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 Boar. ^� WELD COUNTY BOARD OF IL,3% SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY 75,0st t DEPARTMENT OF HUMAN s�Y�r SERVICES By: � ) By' _ _ice/ �./. i �•�_�. ./��1�..�� ' �; �j� Dep +!Clerk to the Board ��. ,,,,, Chair Signature Approval as to Substance: CONTRACTOR Plrig 2 9 2012 WELD COUNTY DEPARTMENT Quality Life Services LLC OF HUMAN SERVICES 11975 Reed Street Broomfi d, CO 80020 By: l • / ?AD C u ty D' e or's Si ature/ to ontrac ors Signature/Date aD/01-a 309 8 Weld County SS-23A Addendum ' WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Smith Agency Inc. and Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this 11 day of u , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of th�ement 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#44882. 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 SO/a-6230 , 1 Weld County SS-23A Addendum 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 2 Weld County SS-23A Addendum 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: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS • NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE IDN SEX TRAILS CASE ID DOB M F WORKER COMPLETING ASSESSMENT HH# IMATE 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 01)One round trip a week ❑1'/:)2 round trips a week O2)3-4 round trips a week. ❑2%:)5 round trips a week O3)6 round trips a week ❑3'/)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month ❑1'%)Two times month O2)Three times a month ❑2%)Once a week O3)Two times a week O3%)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 or special education plan? 0 Basic Maint.)No educational requirements DI)Less than a''/2 hour per day ❑1'/:) '%hour a day ❑2) 1 hour a day O2 /) I''/2-2 hours per day O3)2'/z-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? ❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week ❑1'/:)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) 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 age appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week DI)3 to 4 hours per week D11/2)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2/) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week A 1. How often is CPA/County case management required?(Does not include therapy) ['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/)Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) DI)Less than 4 hours per month O2)4-8 hours per month O3)9-12 hours per month 4 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a I to this child. 4' ta- F. 40, t i - wi !3� �, v I I .�� iU '�Y r e+y 's C t '3', 41 T3 .'"-•,.t w&` P Y .t� Iv ti, b� "s'i.S'.,,Lt,d.art.04 r-An" a8 ¢ - lief&"'` c* a .k4 �, 4'P k�tr, ;.�mliiiieit d"' Y"&tea- v ',.%,51!6 x x ''.1' t i rr , a£ E a e{ r ", C e .:i. ...,...;.:4.1.:5-,'d," s f• '41,4:- r . . ��.. °ts ,� a �v 4 .....-' .Wn? �';�' $�y.,:�.:. .i ..'�-I�. T.-:� .'...�'a,w -.�� . ....;{C .. „� sa. ..�.. x Aggression/Cruelty to Animals ❑ CI CI CI ❑ 0 0 Verbal or Physical Threatening CI 0 ❑ 0 ❑ 0 Destructive of Property/Fire Setting CI 0 CI 0 ❑ 0 ❑ Stealing ❑ ❑ ❑ 0 ❑ 0 0 Self-injurious Behavior ❑ 0 0 [11 ❑ O O Substance Abuse ❑ 0 0 0 ❑ 0 ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 CI 0 0 CI 0 Enuresis/Encopresis 0 0 0 0 0 0 0 Runaway ❑ 0 ❑ 0 ❑ 0 ❑ Sexual Offenses ❑ ❑ ❑ ❑ 0 ❑ 0 5 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS BEHAVIORNEEDS ASSESSBASEDMENT CONTINUED v Please rate the behavior/intensit of conditions which create the need for services that a r r 1 to this child.AlitsthJ k�Y,br"x£ \N {v 'ice' e �'�y �:::' t�.�§ }�1v`ry 'is t § "a Ly„ r "4.Ti "�Yx4 wx. y -441,; !C _ 4#•i. } yh. 'Ys, ' Y Y'0.. li d`.h'- y'` '''a*•?,•+., a'f�.€ r .. ,rk },�, 5I' kT dr "t r�'" 5{ 1W : 'a Ri .‘Th 51 1.:.,-R.. A -J 2'.. Y J 1 '.\'''''. n,''' ',:2 1 'w t v Y : :;R i ... ; 0.".1/200,40.2. 93 } n xr r v a r n 4 BAs 5 s � s*�$ r.4. ........ . .. ..n u ate; Inappropriate Sexual Behavior 0 ❑ 0 0 0 0 ❑ Disruptive Behavior El ❑ ❑ ❑ 0 0 0 Delinquent Behavior 0 0 0 0 0 0 0 Depressive-like Behavior 0 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ O O ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation El 0 0 ❑ 0 0 0 • Eating Problems ❑ 0 0 0 ❑ 0 0 Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care ❑ ❑ El 0 0 0 ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family 0 El ❑ ❑ 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/4 ❑ 2 ❑ 2'/ ❑ 3 ❑ 3% F Weld County SS-23A Addendum ' ' (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ? y ' F3. ,.' "'° it �LSD tf..4 m ,. ,t�'n §+ .n C�.vk4'G,�rv�sl�� a�1p 4'k4,��1 :'t'.e "".4 a" .t v !'•'° I k:11a� '' ti is '-'1: "k- :"t k l § i'±T" s v n<16 4 '# r s r ,::4 ,rile �� EF`�h„4r14_A. 's 41 : 4 d ?lirtc21} r • • • • • 34 (PlS' saz 5' X . n.t„# 1.*!Ci 44ik."r:.+".' 1I y b";iNiE. °`4 ,,. p` witryam, ' 1?):141 q,; X83 $y �' I ; �. * 2 i,t,4w kki i �'` 'w i a • r ?�g y f. qig. �w.�lv t ...,: 9.{zs^n.....,$ �4,1f� *,,;.,.lu,.,l .x`.(:._t,:.' ..n ` .. .... .. ... ..... .. . : ......; '.a Age 0-10...$16.32 p,': a': ($496) :Basic Maint $4.93 day/$150mo Level 0 $0 rokl Fit. County Age 11-14...$18.05 Therapy not needed or provided Basic ($549) No crisis intervention,Minimal CPA by ', Level 0...$0 Maint. SI Age 15-21...$19.27 ' (None) 1,1 Itki ($586) involvement,one face-to-face visit another source, i.e.mental health. �, 3 tad +$.66 Respite Care Lygo ($20) with child per month. :, $19.73 Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo pw 1 !Fil 440 +$.66 Respite Care Minimal crisis intervention as needed € Regularly scheduled therapy, '"„i Level 1 ...$2.99 leIM one face-to-face visit per month with ,t ',a.; ,aa ($20.39 day/$620 mo) child, .:,; up to 4 hours/month. .„ r 2-3 contacts per month ' $23.01 SO 1 1/2 IN -4.66 Respite Care Level 1 1/2 $9.86 day/$300 mo - ----- __ ($23.67 day/$720 mo) .."' 'kI Si $26.30 Level 2 $11.51 day/$350 mo 44‘.,$ Level 2 $9.86/$300 mo -^ 2 . 4.-4.66 Respite Care 'I Occasional crisis intervention as needed, $i, Weekly scheduled therapy, • Level 2..$4.47 two face-to-face visits with child, i`q 5-8 hours a month with 4 hours of ($26.96 day/$820 mo) .. 'ti , ; n ` 2-3 contacts per month :-+c' group therapy. ,,tc tit $29.59 *..4.4'.: n 2 1/2 , e_ +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo a ---- ------------ ll ($30.25 day/$920 mo) . 4v 41 ' 4' $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..$6.02 weekly face-to-face visits with child, more ($33.54day/$1020 mo) and intensive coordination of dt than 1 person, i.e.family therapy, *-` 1k . IN multiple services. for 9-12 hours/month) r>; ', $36.16 �$ § 3 1/2 k'. +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo �^ * --------_ ($36.82 day/$1,120 mo) ? .4rdiSal $39.45 k��s Level 4 $18.08 day/$550 mo c e) Level 4 $14.79/$450 mo ..r j34.ig +$.66 Respite Care Ongoing crisis intervention as needed, ,-., Regularly scheduled weekly A,- 4 ' multiple sessions,can include ,,.; TRCCF which includes high level of case '. more „° a Level 4....Neg. Drop Down management and CPA involvement with " than 1person, i.e.family therapy, (. ($40.11 day/$1220 mo) 9 f • child and provider and 2-3 face-to-face for 9-12 hours/monthly. �.w contacts .er week minimum. .tea.. r g aF Assess/ ',r' vi ssi'1 Emergency a $30.25 day/$920 mo d " Level (Includes Respite) $13.15 day/$400 mo .4.../::: p Rate Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum I IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF ��. SLa OF THE WELD COUNTY DEPARTMENT OF HUMAN ^ 'aQQ SERVICES Itst SY? Dep .Clerk to the Board Chair Signature Protem Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT Smith Agency Inc. OF HUMAN SERVICES 14394 E. Evans Ave Aurora, CO 80014-1408 By: teltl By: dy 1/// 2 Co ty Direc r s Sign re/Dat Contractor's Signature/Date Go/a- 0739 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Special Kids Special Families and Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this v2 day of i�¢t{ , 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#43184. 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 02O/62- a. #y 1 Weld County SS-23A Addendum 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 2 Weld County SS-23A Addendum 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: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS • NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX 'TRAILS CASE ID jDOB M F I I WORKER COMPLETING ASSESSMENT r# 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 01)One round trip a week 01%)2 round trips a week 02)3-4 round trips a week. O2%)5 round trips a week O3)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 01)Once a month 01%)Two times month ❑2)Three times a month ❑2%)Once a week O3)Two times a week O3%)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 or special education plan? ❑ Basic Maint.)No educational requirements 01) Less than a''/z hour per day ❑1%) '/z hour a day O2) I hour a day O2 '/:) 1'1-2 hours per day O3)21/2-3 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? O Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 11 to 14 hours per week 0 3)Constant basis during awake hours O3%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? O Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week O3%)2 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.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%)Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County SS-23A Addendum • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..l to,this child. SNj11tT EL l it ip i m t .: �.f'�.'kx ' k L �: k �4s g:44.: 1 'i ,_ t f 1 r'��Av 'F' y Y, � `f � `v�y` �. 'Nd tit �a� k YM, a ' 1{4P.1. �4 .M' n,. t . i` � a A .. i ,�, A 1 h +. 3� ry -dk t Y� �rk �S'qz��"92' �L `Tt 'FR Nr �}'�Y..'3 } ( , a ........s,:'' . �a y k�gFg3�.,i uni i ' " q�� ,.r k - �. 7an "' Aggression/Cruelty to Animals ❑ 0 0 0 0 0 0 Verbal or Physical Threatening ❑ 0 ❑ 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 ❑ 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis o ❑ 0 0 ❑ 0 0 Runaway O 0 0 0 ❑ 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 5 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. t t kre � 'sk r'° p r'A' t f i't s a ! i.p3� e # r' s zx J x ! n . .. a+t+�.t 1 .1+ v ' � 'h a (fi ry. 4 Y''itk. al•. ,,`9St.;?.3: k t .t: ; 3 44' ^it � :��"r ,%� � k'pt.�, ... r*. e ,e � J �°a $ut. r� wx Inappropriate Sexual Behavior 0 ❑ ❑ ❑ ❑ 0 ❑ Disruptive Behavior ❑ ❑ 0 0 0 0 0 Delinquent Behavior ❑ 0 ❑ 0 0 ❑ 0 Depressive-like Behavior ❑ ❑ ❑ ❑ 0 ❑ ❑ Medical Needs ❑ ❑ ❑ ❑ ❑ 0 ❑ (If condition is rated"severe". please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ 0 0 0 0 Eating Problems ❑ ❑ ❑ ❑ 0 0 ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ 0 ❑ ❑ 0 0 ❑ Education ❑ ❑ ❑ ❑ ❑ 0 0 Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) El0 ❑1 El1'/z ❑ 2 ❑ 2Yz ❑ 3 ❑ 3''/ 6 Weld County SS-23A Addendum (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Itliiii >2 s i n as .- t § 1 « yb.�.x� : Pa i rt '`i a l. IK ;Att,: ' Y' . 4 i v.4) 4 S • • t * •i ^ t .. x .any L �tr- ' � '� r r• 4 t `, 4 a •c.pA •Iii ''' ' Ss MC '5 S x h 4 fi .e, x..aseii! �w..�il.. '�*R ;..4A a`a Ao.(.;.� .,T _, ,4?,r, ti:'= � .. ,.ka' ''' Age 0-10...$16.32 tk y • e„ ($496) Basic Maint $4.93 day/$150mo °E4' Level 0Val $0k County Age 11-14...$18.05 4'; Therapy not needed or provided Basic " ($549) No crisis intervention,Minimal CPA by Level 0._$0 Maint. x Age 15-21...$19.27 (None) ($586) involvement, one face-to-face visit another source, i.e.mental health. 2 it ii,' $.66 Respite Care kk** ($20) with child per month. .r; ; Oa PAT $19.73 Level 1 $8.22 day/$250 mo ;; Level 1 $4.93/$150 mo k +$.66 Respite Care Minimal crisis intervention as needed :p 1 Regularly scheduled therapy, ,i t one face-to-face visit per month with '")=S 'a Level 1 ...$2.99 It ($20.39 day/$620 mo) child, 6 up to 4 hours/month. is ',',a ,, 2-3 contacts per month j Yz-, °d" $23.01 : v,'.. 11/2 t +$.66 Respite Care Level 11/2 $9.86 day/$300 mo a'' .�k kE$ ($23.67 day/$720 mo) il Y?xi ��:,,� S i $26.30 Level 2 $11.51 day/$350 mo „ Level 2 $9.86/$300 mo " 'I 2 +$,66 Respite Care VIP, Occasional crisis intervention as needed, ti,' Weekly scheduled therapy, Level 2..$4.47 -'" two face-to-face visits with child, } 5-8 hours a month with 4 hours of ', L3 ($26.96 day/$820 mo) +t, x,'` 2-3 contacts per month : group therapy. (t $2a59 e Care s '' 2 1/2 ."r „ +$.66 Respit Level 2 1/2 $13.15 day/$400 mo f " T ($30.25 day/$920 mo) $32.88 Level 3 $14.79 day/$450 mo „li Level 3 $14.79/$450 mo , 4!, +$.66 Respite Care Ongoing crisis intervention as needed Regularly scheduled weekly ''! `3 - multiple sessions,can include '_ 3 4 weekly face-to-face visits with child, more Level 3..$6.02 ti ($33.54day/$1020 mo) and intensive coordination of than 1 person, i.e.family therapy, T; : i multiple services. I1.( for 9-12 hours/monthly. da9 $36.16 } hw.s 3 1/2 ill,i„ +$.66 Respite Care - Level 3 1/2 $16.44 day/$500 mo � ', ($36.82 day/$1,120 mo) ' Iftiai 145.1.: ,,,,:all ;z y,9 1;A $39.45 Level 4 $18.08 day/$550 mo T`a. Level 4 $14.79/$450 mo S +$.66 Respite Care Ongoing crisis intervention as needed, p Regularly scheduled weekly ". 4 . ,r' multiple sessions,can include , which includes high level of case =„�;� more TRCCF ,F 9 :,, kt; Level 4....Neg. Drop Down ," management and CPA involvement with i'` than 1person, i.e.family thera ($40.11 day/$1220 mo) 9 3r: PY, child and provider and 2-3 face-to-face A for 9-12 hours/monthly. `t `Y contacts eer week minimum. „ Assess/ ' ) ,m� Emergency ik4y $30.25 day/$920 mo333.43i '`" Level I (Includes Respite) $13.15 day/$400 mof Rate ,_, Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum • 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 Visa OF THE WELD COUNTY �^c�-�• ,p� 't DEPARTMENT OF HUMAN 1/42 SERVICES 1161 t By: B (-4Thfil(k. Deput erk to the Board ► ' y Chair Signature Proga! Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT Special Kids Special Families OF HUMAN SERVICES 424 W Pikes Peak Ave Colorado Springs, CO 80905 By: By. C u ty Dire tor's S' ature/ ate Co Ira or's Signature ate &©r)? a 30, 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Whimspire CPA and Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made this I day of , 2012, are added to the referenced Agreement. Except as modified hereby, all terms oft e 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#19562. 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 1, 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 SIX--9-a'SD5 Weld County SS-23A Addendum 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 2 Weld County 55-23A Addendum 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: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX FIRAILS CASE ID IDOB M F J WORKER COMPLETING ASSESSMENT IIHtt IRATE 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 DI)One round trip a week ❑1'/z)2 round trips a week ❑2)3-4 round trips a week. ❑2%z) 5 round trips a week 03)6 round trips a week 03%) 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 01)Once a month 01%)Two times month 02)Three times a month ❑2'/)Once a week 03)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 or special education plan? 0 Basic Maint.)No educational requirements 01)Less than a''/z hour per day 01%) %z hour a day ❑2) 1 hour a day 02 1/2) 1'/2-2 hours per day 03)2%z-3 hours per day 03%)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 ❑1) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) II to 14 hours per week 0 3)Constant basis during awake hours ❑3'/z)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2)8 to I0 hours per week ❑2%z) 11 to 15 hours per week ❑3) 16 to 20 per week 03%)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.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%z) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00)Not needed or provided by another source(i.e. Medicaid) 01)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. :,,E MCIP,IftcYl a}:' Y'�.. .... & . hP₹ '. h- Y ' F ,. K. .y g':y K:It4,..t "i, x :1;4:;< ,gam 1 n } • "8c L W "u * G �s� 4 t $,'St . x . �fic ''a3,;x .I " �',+ ' '4k t e tau'. -,.i t�°�t ; IE s„27 :a°.'d: .. 't .. ,s".'. :'.1. —4',°}.. P,.,.x a.'. w �, 3,....'. ° ra,�x; Aggression/Cruelty to Animals ❑ ❑ 0 0 ❑ ❑ ❑ Verbal or Physical Threatening ❑ 0 0 0 ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 ❑ 0 0 ❑ 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 ❑ 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis O 0 0 0 0 0 ❑ Runaway ❑ 0 0 0 0 0 0 Sexual Offenses O 0 0 0 ❑ 0 0 5 Weld County SS-23A Addendum (Exhibit B) • • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. `« :t. 'v', i ' t I al t id-'_, a. w v i e..t r , ' . t t i i �' v LtmUr :ac'�* 4i am. C v 4` r'"" cu w*v `.c�,l`�"�v, °�'�y�fpa »Y n a�t .. *�v"' i s 'a ..II'r�,ar. '. x� a C i 'v 'ma. 's' �, r Isar, s. a 'fit ts4 a },si'3,fx r'' }§' i�L r .Ci C +^ t� Y z"a.,�. "r ^w „i: {a �""ry w`i�a 'rev„v •*�} 4 a x a s w ; .. { � �50.� _ � _ 104 • � ��'}iti:Yk' tri�x...�9.Yvi't�p:�wi�..i.d wr.. �..xY'ild.'+. 'ry . S.`..,S L fie. - dw .a. Inappropriate Sexual Behavior 0 0 0 0 0 ❑ 0 Disruptive Behavior ❑ 0 0 0 0 ❑ 0 Delinquent Behavior ❑ 0 0 0 ❑ 0 ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ 0 0 Medical Needs (If condition is rated"severe ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ 0 ❑ ❑ 0 Boundary Issues ❑ 0 0 0 ❑ ❑ 0 Requires Night Care ❑ ❑ 0 ❑ ❑ 0 0 Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ o ❑1 ❑ 1'/ ❑ 2 ❑ 2'h ❑ 3 ❑ 31/2 6 Weld County SS-23A Addendum (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE '"�a*' R eN'�f c d,F+ k v '. l'rx?,.'vP t 1rRei 1 a , 3. e 1 we t" a i r&" "; It Y1s.; e` 1 ? J::"w$d ,2 x ; irItTiC) ° rt':.'�40,611 Fen, x �m >r' m h4 P ' �:tt: 'tea ], e .. '4 y" ire t '°gay' i s.I�,{ ri 6 , rtt≥ d ;awes , ..,. . w i ... ;•:4I;l14-a. v.u .c•✓,. . .. _..°x t V:a 17:..l'Cli1 F - t i:if;.k.. °^u.... .a �� ti,; t^y.,�:.— .... ... < a .n... r;. . .. �.$ m Age 0-10...$16.32 : c'z rt ($496) , Basic Maint $4.93 day/$150mo Level 0 $0 >5 Counk Age 11-14...$18.05 Therapy not needed or provided .2 Basic 'x ($549) No crisis intervention, Minimal CPA by ' Level 0...$0 Maint. r := Age 15-21...$19.27 ' x '1 (None) 4 ($586) 1F• involvement,one face-to-face visit another source,i.e.mental health. f a +$.66 Respite Care '" `,:. ($20) a with child per month. kiiiR P $19.73 ' Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo -42 1 ₹ +$.66 Respite Care Minimal crisis intervention as needed Regularly scheduled therapy, kac l` one face-to-face visit per month with , >� Level 1 ...$2.99 ($20.39 day/$620 mo) child, ,'Vv.; up to 4 hours/month. t `. PO +P 2-3 contacts per month r i �, $23.01 +vi ;r•"* 1 1/2 *%.d +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo a t x di ($23.67 day/$720 mo) )`'=,1MA ''a $26.30 Level 2 $11.51 day/$350 mo rl Level 2 $9.86/$300 mo c,r +$.66 Respite Care Occasional crisis intervention as needed, i, Weekly scheduled therapy, .e5 2y, �. �'c' Level 2..$4.47 ii two face-to-face visits with child, 5-8 hours a month with 4 hours of t) a�s ($26.96 day/$820 mo) ,, wt, , Y ' „ 2-3 contacts .er month .rou. there. . H I $29.59 # " r 2 1/2 +$.66 Respite Care ; Level 2 1/2 $13.15 day/$400 mo 3 ($30.25 day/$920 mo) '� 14 a fat y +. ki) $32.88 ', Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo 1 r 3 +$.66 Respite Care i''' Ongoing crisis intervention as needed, 1...11... Regularly scheduled weekly multiple sessions,can include `% 3 ' weekly face-to-face visits with child, more Level 3..$6.02 ($33.54day/$1020 mo) Fear and intensive coordination of than 1 person, i.e.family therapy, ''g I; . :: multiple services. for 9-12 hours/monthly. +°{ OS $36.16 I ': a. 3 1/2 +$.66 Respite Care ₹v Level 3 1/2.........$16.44 day/$500 mo ($36.82 day/$1,120 mo) }1. °'ill ; to ft . $39.45 li la Level 4 $18.08 day/$550 mo trfabl.s Level 4.........$14.79/$450 mo ai +$.66 Respite Care Ongoing crisis intervention as needed, fill Regularly scheduled weekly �. a multi le sessions,can include PM TRCCF a. which includes high level of case p more § Level 4....Neg. Drop Down management and CPA involvement with than 1person, i.e.family therapy, A ($40.11 day/$1220 mo) 0. 9 r ,_y ueT{ ":: child and provider and 2-3 face-to-face polt for 9-12 hours/monthly. -4 '�'�a. contacts .er week minimum. ,,' ,,,, • 1:',O I Assess/ T Emergency $30.25 day/$920 mo tr"a Level (Includes Respite) � $13.15 day/$400 mo k . l WI M Y,g Rate -¢ R Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum • 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 5 � �� OF THE WELD COUNTY 1 _°a1 DEPARTMENT OF HUMAN J/ "1+ �� SERVICES • ,p/• 4 /y1 Dep Clerk to the Boar%re j I Orr trifled Chair Signature Proten Approval as to Substance: CONTRACTOR AUG 2 9 2012 WELD COUNTY DEPARTMENT Whimspire CPA OF HUMAN SERVICES 4575 Galley Rd, Suite 400A Colorado Springs, CO 80915-2750 By: By: tv Wyatt g t ZDIZ #Di '( S ontractor's Signature ate 020/S-ageY 8 Weld County SS-23A Addendum Hello