HomeMy WebLinkAbout20122096.tiff MEMORANDUM
DATE: August 6,2012
��/�� TO: Sean P.Conway,Chair,Weld�ou�ty B rd ommissioners
V ..G OU N T Y-,71
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FROM: Judy A.Griego,Director,Human Ser ices Deq'rtme
RE: Agreement to Purchase Out-of-Home Placement Services and
the Weld County Addendum to the Agreement to Purchase
Child Placement Agency Services between the Weld County
Department of Human Services and Quality Life Services LLC
to be Placed on the Consent Agenda
Enclosed for Board approval is an Agreement to Purchase Out-of-Home Placement Services and the
Weld County Addendum to the Agreement to Purchase Child Placement Agency Services between
the Department and Quality Life Services LLC. This Agreement was reviewed by Pass-Around
Memorandum dated July 31,2012,and approved for placement on the Board's Consent Agenda.
Below are the major provisions of the attached Agreements:
No. Facility Name/Term Facility Type/Location Daily Rate
I Quality Life Services LLC Child Placement Agency Services $16.32-$40.11
Child Residential Habilitation Program
June 1,2012—June 30,2012 Broomfield,Colorado
If you have any questions,give me a call at extension 6510.
2012-2096
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AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
® CHILD PLACEMENT AGENCY SERVICES (CPA)
Z CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP)
❑ GROUP HOME/GROUP CENTER CARE
❑ INDEPENDENT LIVING
❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF)
❑ RESIDENTIAL CHILD CARE FACILITY (RCCF)
❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM
❑ SHELTER CARE
❑ SUBSIDIZED ADOPTION
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this / day of 0,C��7o it between the Weld
County Department of Social/Human Services hereinafter called "County" and Quality
Life Services LLC, 11975 Reed Street, Broomfield, CO 80020, hereinafter called
"Contractor." THIS AGREEMENT, shall include all children placed by the Weld
County Department of Social/Human Services and Quality Life Services LLC.
A child specific addendum, identifying individual service needs, must be completed and
attached to supplement this agreement for each child being served by the facility. If this
is a CPA placement, the child specific addendum should also address how administrative
services will be provided in the event the child is placed for adoption in a foster home
supervised by the CPA.
WHEREAS, the Colorado State Department of Human Services, hereinafter called"State
Department" is authorized to provide social services to individuals and families of
individuals through its agents, County Departments of Social/Human Services, and
WHEREAS, the County is authorized to purchase certain services for eligible children
under State Department rules, and
WHEREAS, the County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child
Care Facility, certified Psychiatric Residential Treatment Facility, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
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NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings
the County and the Contractor agree as follows:
1. This Agreement shall be in force from the date of the agreement, June 1,
2012, until the end of the Colorado fiscal year, June 30, 2012. Any child
may be removed from the facility prior to the end of the fiscal year by the
county department.
2. This Agreement may be renewed only by entering into a new written
Agreement such as this Agreement signed by the authorized
representatives of the parties. Except as otherwise provided above, either
party shall have the right to terminate this contract by giving the other
party thirty (30) days notice by registered mail, return receipt requested. If
notice is so given, this contract shall terminate on the expiration of the
thirty (30) days or until the eligible child(ren) can be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease, but the
parties shall not be released from the duty to perform their obligations up
to the date of termination.
3. This Agreement is in lieu of and supersedes all prior agreements between
the parties hereto and relating to the care and services herein described.
SECTION I - DESCRIPTION OF SERVICES TO BE PURCHASED
1. The total rate of payment for care and services under this Agreement shall not exceed:
the established rate for the PRTF; for CPA placements, the negotiated rate or the
approved vendor rate; for TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements the negotiated rate
or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal
rate. The total rate of payment for care and services for other service types will be as
negotiated between the County and the Contractor. Medicaid rules shall govern activities
to be covered in the daily rate paid to PRTFs.
The amount paid for purchased care and services for less than a full month will be based
upon the daily rate.
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1, F (12 CCR 2509-5).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
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County. The County has responsibility for the decision to return the child to the facility,
with input from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the Family Service Plan/Individual Plan of
Care.
5. Any transportation costs to be incurred on behalf of a child in placement, which are to
be borne by persons, or agencies, which are not a party to this contract, shall be specified
in the treatment/service plan, and those persons shall acknowledge their responsibility by
signing the treatment/service plan.
SECTION II - LEGAL STATUS AND AUTHORIZATIONS
1. Such permission as is held by the County is hereby granted to the Contractor to
authorize routine or emergency medical and dental treatment except that:
a. Medical or dental care shall be provided by personnel duly licensed by law as required
by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery,
ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not
included in the monthly rate. The cost of any items not covered by Medicaid will be
negotiated between County and Contractor. Medicaid rules shall govern activities to be
covered in the daily rate paid to PRTFs.
2. County and Contractor shall insure that the child(ren) is enrolled in the Early and
Periodic Screening, Diagnosis and Treatment Program.
3. It is agreed and permission is granted for the child(ren) to participate in planned
recreational and social activities of Contractor, including supervised off grounds
excursions and extended trips within the State, provided that Contractor has written
permission from County and legal guardian for any trips out of Colorado for any reason
and any planned absence from the facility of over seven (7) days within a consecutive 30-
day period. Such written permission may be in the treatment/service plan. Further,
Contractor and County will also secure, where possible, permission from parents or
guardians of the child placed with the Contractor. Any planned absence of more than 24
hours for children placed in a PRTF is not Medicaid reimbursable.
4. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status which comes to their attention.
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SECTION III - REASONS FOR REFERRAL, TREATMENT PLAN, AND
PROGRESS REPORTS
1. County and Contractor agree and understand that the reasons for referral, which
necessitate purchasing services for children are specified in the attached child specific
addendum and Family Services Plan. Any other relevant information concerning these
children that does not necessitate purchasing services is also included in the addendum.
2. County and Contractor shall develop an initial plan that addresses the immediate
and/or emergency needs of the child within 72 hours of admission for children in
TRCCFs, RCCFs or group homes except PRTF. County and Contractor shall formulate
an initial individual plan of care within 14 calendar days after admission for children in
TRCCFs, RCCFs or group homes except PRTF. The placement date is that date noted in
the attached child specific addendum included with this contract. The Child's Family
Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities.
Modifications to this plan shall be agreed to in writing on the plan or as a supplemental
document.
3. County and Contractor shall formulate an initial individual plan of care for children in
PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care
must be completed by the multidisciplinary team within 14 calendar days from the
placement date. The placement date is that date noted in the attached child specific
addendum included with this contract. Modifications to this plan shall be agreed to in
writing on the plan or as a supplemental document.
4. The individual plan of care shall be goal oriented and time-limited and shall:
a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with
clinical and other needs including the child's presenting problems, physical
health, emotional status, behavior, support system in the community, available
resources, and discharge plan.
b. Include specific goals and measurable objectives, expected dates of
achievement, specific discharge and transitional/after-care and follow up services
criteria to be met for termination of treatment.
c. Specify the type, frequency, and duration of clinical therapy services,
rehabilitation services, medication management, emergency services, initial
assessment, documented treatment modifications, and other services determined
to be necessary to meet the child's specific goals.
d. Specify that all TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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e. Identify the provision of, or the referral for, services other than TRCCF services
and shall document any court ordered treatment including identifying the agency
responsible for providing the court ordered treatment.
f. Anticipated living arrangement for the child at the date of discharge;
g. Anticipated educational arrangement for the child at the time of discharge;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, RCCFs and other contractor types
other than PRTF, shall conduct a monthly review of each plan to evaluate whether the
short-term and long-term goals have been achieved or not achieved. These parties shall
provide the County with written reports which address changes to the child's physical
condition, psychological and social functioning, changes in the child's family situation,
educational progress, significant incidents or disciplinary actions, and progress made to
achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence
reports to be received by the County 15 calendar days prior to judicial or administrative
hearings or reviews when provided with 30 calendar days advance notice of such dates by
County.
6. Every 14 days, PRTFs shall provide the County with written reports which address
changes to the child's physical condition, psychological and social functioning, changes
in the child's family situation, educational progress, significant incidents or disciplinary
actions, and progress made to achieve goals specified in the treatment plan.
SECTION IV - CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Human Services, the Colorado Department of Health Care Policy and Financing (if
appropriate), the State of Colorado and any applicable federal laws and regulations, as
such, which may be amended from time to time, and shall be binding on Contractor and
control any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law and rule.
3. Not charge any fees to children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract
without the express written approval of the Director of the County Department or his/her
appointed designee.
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5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act
of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security
Act of 1975 as revised, and provide confidentiality of information concerning the child in
compliance with the Health Insurance Portability and Accountability Act (HIPAA).
6. Maintain during the term of this Agreement a liability insurance policy of at least
$25,000 for CPAs and $400,000 for PRTFs, TRCCFs, and RCCFs for property damage
liability, $150,000 for injury and/or damage to any one person, and $600,000 for total
injuries arising from any one accident.
7. Maintain during the terms of this Agreement a fidelity bond of at least$25,000 or two
(2) months gross receipts, whichever is greater, covering the activities of any of its
officers, agents or employees responsible for the implementation and/or administration of
this contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
8. Indemnify County, Colorado Department of Human Services, Colorado Department of
Health Care Policy &Financing, and the State of Colorado against any and loss against
all claims and actions based upon or arising out of damage or injury, including death, to
persons or property caused or sustained in connection with the performance of this
contract or by conditions created thereby, or based upon any violations of any statute,
ordinance, or regulation and the defense of any such claims or actions.
Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county
departments.
9. In regards to University of Colorado contractors only, the contractor shall be
responsible for its own wrongful or negligent acts or omissions or those of its officers,
agents, or employees while performing their professional duties to the full extent allowed
by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or
waiver of the application of the Colorado Governmental Immunity Act set forth in §24-
10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the
University of Colorado, its employees or agents under this Agreement.
10. Maintain service program records, fiscal records, documentation and other records,
which will sufficiently and properly reflect all direct and indirect costs of any nature
incurred in the performance of this Agreement. The above shall be subject at all
reasonable times to inspection, review or audit by federal, Colorado Department of
Human Services, Colorado Department of Health Care Policy & Financing, or county
personnel, and other persons authorized in writing by the Executive Director of the
Colorado Department of Human Services.
11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the
initial home study, the SAFE study update, annual certification updates and related
materials when requested by the County within fourteen working days of the request. At
all other times the Contractor shall make home studies and related materials available to
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the County for review, at a location agreed upon by the County and the Contractor,
during regular business hours.
12. Bill the County for services rendered, using the required form. This form is to be
mailed to the County by the last day of the month of care. Billings for PRTFs shall be
made to the MMIS System only. Billings for TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, CPAs and other contractor
types shall be made to the County only. Contractor will not be paid by the county when
billing is not received by the County within 30 calendar days following the billing due
date.
13. Attend and participate in Administrative Reviews for children in placement with the
Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall
encourage children over the age of twelve to attend their Administrative Reviews.
Participation may be in person or by teleconference.
14. The Contractor shall pay the foster parent the amount agreed upon with the county as
the child maintenance or room and board. Any payment to the foster parent in excess of
the child maintenance or room and board amount shall be treated as income to the foster
parent.
SECTION V - COUNTY SHALL:
1. Determine eligibility of the children under this Agreement for placement and medical
coverage. Medicaid rules and regulations shall govern determination of Medicaid
eligibility.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Human Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate when billing is submitted as described in Section IV, Number 10
(above).
4. Abide by all the rules and regulations of the Colorado Department of Human Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. If this agreement covers an initial placement for a child, the Contractor may receive a
clothing allowance in accordance with State Department rules.
6. Monitor children's progress in accordance with the treatment/family services plan and
the requirements of Colorado Department of Human Services rules and provide
consultation to Contractor in relation to the services purchased under this Agreement.
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7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled
review.
8. Involve Contractor in planning for the child and give the Contractor a copy of the
Family Services Plan at time of placement or as soon as completed and when updated or
revised.
9. The County shall seek recovery from the TRCCF, RCCF, CPA or other contractor type
for any non Medicaid payment amounts that have been misused as defined in rules. The
County may withhold subsequent payments to recover any funds misused by the TRCCF,
RCCF, CPA or other contractor type. The County shall seek recovery of any remaining
funds as a debt due the County for the benefit of the state. The TRCCF, RCCF or CPA
may appeal the decision to recover or withhold subsequent payments as defined in rules.
10. The County shall identify the amount agreed upon with the Contractor to be paid to
the foster parent for the child's room and board. Such amount will be the same as shown
in Trails for the child's maintenance.
11. Reimbursement rates that are negotiated between the County and the Contractor shall
be for allowable costs in one or more of four primary components: child maintenance,
administrative services, administrative maintenance, and treatment. Contractor type will
determine which of these four components will be included in the reimbursement rate.
SECTION VI - GENERAL PROVISIONS
1. The Parties to this Agreement intend that the relationship between them, contemplated
by this Agreement is that of employer independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of the County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing availability
of State of Colorado, county, and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor will be
released from responsibility for loss or damage to such personal items.
4. This Agreement is intended to be applied in conjunction with the child specific
addendum and family services plan as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other amendment
hereto shall have any force or affect whatsoever, unless embodied herein in writing. No
subsequent notation, renewal, addition, deletion, or other amendment hereto shall have
any force or effect unless embodied as a part of this written Agreement. This section shall
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not be construed as either prohibiting the periodic amending of the family services plan
or appending a county designed addendum to this agreement.
5. The contract shall permit the State Department to monitor service program, fiscal and
other records sufficiently to assure the purchase of services in this Agreement are carried
out for the benefit of the aforementioned client. Monitoring may occur through review of
program reports, on-site visits where applicable and other contracts as deemed necessary.
The Contractor understands that the State Department may provide consultation to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
A. All reimbursement requests shall be submitted to and approved by the
appropriate County staff Reimbursement for placement services shall be paid
from the date of admission up to, but not including, the day of discharge.
Furthermore, Medicaid payments for PRTF and CHRP placements are permitted
on the day of discharge in compliance with regulations promulgated by the
Colorado Department of Health Care Policy and Finance. Fee for Service will be
reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to
funds encumbered in this contract and shall also include Medicaid funds for PRTF
and TRCCF therapeutic programs and CHRP placements paid by the Department
of Health Care Policy and Financing. Payment for placement services will not be
provided for clients on "runaway" status unless the County has previously
approved it. Reimbursement requests for therapy costs for clients enrolled in
PRTF, TRCCF, and CHRP programs shall be submitted to the Medicaid Fiscal
Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly
basis.
In the event that a Contractor receives payment for a per diem discharge day,
regardless of funding source,the Contractor shall refund those dollars forthwith.
B. The purpose of these requirements is to provide minimum assurance that the
Contractor has adequate accounting and budgeting information available to allow
management to maintain a financially viable enterprise and to demonstrate
financial accountability to the county departments of human/social services and
Colorado Department of Human Services for the use of public funds.
(1) The Contractor must have in place a double entry accounting system and all
financial transactions must be posted to this system. Financial statements,
prepared from information provided by this system, shall be presented in
conformity with U.S. generally accepted accounting principles (GAAP). The
Contractor must also have adequate time keeping and cost allocation systems to
allocate salary cost and indirect cost to appropriate cost centers. Books and
records of the Contractor shall be subject, at any reasonable time, to inspection,
audit or copying by appropriate Federal, State or county personnel, or such
independent auditors or accountants as may be designated by these personnel.
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(2) All billing by the contractor must be in a format approved by the fiscal agent
or county. Contractors must bill the fiscal agent and county at least once a
month. Contractors may bill twice a month, on the 15th and last day of the
month, for services rendered. Bills will be returned unpaid if the bills do not
conform to the approved format or the documentation is inadequate.
(3) All Contractors whose total annual expenditures are $100,000 or more shall
submit an annual audit of their financial statements by an independent certified
public accountant. Contractors with total annual expenditures less than $100,000
may submit an audit as described above or may submit compiled or reviewed
financial statements, prepared in accordance with generally accepted accounting
principles. If the Contractor is a government agency that has an independent audit
done by another agency of that government, its audited financial statements,
prepared in accordance with generally accepted accounting principles for state
and local governments meet this requirement. The audited, compiled or reviewed
financial statements of PRTFs, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs and RCCFs and Attn: Audit Division Director
for CPAs) within 180 days after the contractor's fiscal year end. The audited
financial statements and supplementary information defined in regulation for
various agencies shall be presented as described in Section VI, B (1), above and
must contain sufficient detail to provide evidence of financial accountability
under the terms of this contract and controlling state regulations. Contractors that
are a subsidiary of a parent organization must submit separate financial statements
for the subsidiary that detail each of the Contractor's facilities and/or programs
that provide services for the Colorado Department of Human Services and also
must provide a reconciliation of these financial statements to the consolidated
financial statements of the organization as a whole. When applicable,the
Contractor must comply with the audit requirements found in the Single Audit
Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of
Management and Budget (OMB) Circular A-133, Audits of States, Local
Governments, and Non-Profit Organizations including subsequent revisions, and
appropriate audit and financial reporting requirements as defined in State laws,
rules, and regulations.
(4) If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted. If the contractor is a CPA, then sanctions of the contractor may occur
for failure to submit.
(5) In cases where documentation does not exist to support audit information or
services provided, contractor will be required to repay all funds received for
which documentation does not exist.
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(6) In cases where audit deficiencies are noted, a plan of corrective action shall be
submitted to the State Department's Audit Division for approval within 4 months
of the date of the audit.
(7) Failure to comply with any of these requirements, including items on the
addendum is justification for the County to impose fiscal sanctions, penalties, or
cancel the contract.
6. In the event this contract is terminated, final payment to the Contractor may be
withheld at the discretion of the County until final audit. Incorrect payments to the
Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the
Contractor either by deduction from subsequent payments under this contract or other
contracts between the County and the Contractor or by the County, as a debt due to both
the State of Colorado, the Colorado Department of Human Services and the County. The
waiver of any violation shall not be construed as a waiver of any other or subsequent
violation of this contract or appropriate statutes and regulations.
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
ATTEST: Weld Count Clerk to the Board WELD COUNTY BOARD
OF SOCIAL SERVICES,
n ON BEHALF OF THE
' ',../—',) ..21 NX WELD COUNTY
144-t"t1 -1 DEPARTMENT OF
ism(lit
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By: ' F^' By:
Deputy lerc to the Board Chair Signature
AUG 0 8 20c3
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Quality Life Services LLC
OF HUMAN SERVICES 11975 Reed Street
Br mfield, C 80020
By By.
f hector
Quality Life Service (yy oei
11976 Reed Street Sults 1
Broomfield,CO 80020
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SS-23A revised 2/09 ��%�a� �q�
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
June 1, 2012 through June 30, 2012.
The following provisions, made this 1 day of —u.& 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#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 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
j Weld County SS-23A Addendum
9. screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays,the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
10. 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.
11. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County
Department of Social Services to shorten the duration of placement.
12. Add Paragraph 16 to Section IV. Have medical 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.
13. 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.
14. 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,
Therapeutic Residential Child Care 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
2 Weld County SS-23A Addendum
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental.beneficiary only.
16. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between 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# rAEX F I!TRAILS CASE ID DOB
I
WORKER COMPLETING ASSESSMENT �IH# I 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 ID l)One round trip a week 01%)2 round trips a week
❑2)3-4 round trips a week. ❑2'/)5 round trips a week O3)6 round trips a week
❑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
O2)Three times a month ❑2%z)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 of
special education plan?
O Basic Maint.)No educational requirements ❑1)Less than a''/z hour per day O11/4) 1/4 hour a day
O2) I hour a day O2 'A) I''/z-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 ❑1) Less than 5 hours per week ❑1%)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 age appropriate needs with feedin
bathing,grooming, physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'%)5 to 7 hours per week
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.
❑1/)Face-to-face contact one time per month with child and occasional crisis intervention.
❑2)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2' )Face-to-face contact three times per month with child and occasional crisis intervention.
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) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addend
(Exhibit B)
•
WELD COUNTY DHS
•
BEHAVIORNEEDSBASED ASSESSMECARE NT
Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child.Pcdiivi��s,� d. k; 'x-„ "$Ac. xv � alt hesi'2 t *so-sasi,,,,,,::;:,:z..,,,,:i.1:::
r",,"'�a �a. -;:.'i %;rs ttt:i4 €4iiiami = . ; ≥ ,yi [,�4 �,
"•
y y�. #sx l' ' ' a �t �g� ter .: ° � c ,'k�its, t AarH t
iu vrc i y:T 4 "y�s
ss tip} Y �a. . +... . ` ss �.
a. s.. . :'k` "� 4v A�iik'_w.to . .&S', v ' .. . .y Y..'" . ,e ' ...-.-
,4.1::::
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
❑ ❑ 0 0 0 0 0
Substance Abuse
❑ 0 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 0 0 0 0
Enuresis/Encopresis
❑ ❑ 0 ❑ 0 0 0
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
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,.l to this child.
n }x,, ark �`a+'' ' ' "rj , ik° "W,o- y +., a�j 6
u „ Rr,� =��v"� ..: +'�5. x�+,y3a Qs �K,'.e ' d v
3_'
$ c s*t:W N � i +§. 4h4ri {spa f' 4s
„ vk a'°� .,,� a°.,,,s. .p. r, 6 �i,� roil a o-'qt r
.... ..,rest: r 3 `:Mta` t,{ ' ..p.. '3,111
`
Inappropriate Sexual
Behavior ❑ El 0 0 El El 0
Disruptive Behavior
❑ ❑ El El El 0 ❑
Delinquent Behavior
❑ ❑ El ❑ 0 0 0
Depressive-like Behavior
❑ El 0 El 0 El El
Medical Needs
(If condition is rated"severe', ❑ El El 0 ❑ 0 ❑
please complete the Medically
fragile NBC)
Emancipation
El 0 El El 0 0 0
Eating Problems
El El 0 El El El 0
Boundary Issues
El El El El El El El
Requires Night Care
El El El El El El El
Education
El El El ❑ El El El
Involvement with Child's
Family El El 0 0 0 El El
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'h ❑ 3 ❑ 3'/
6 Weld County SS-23A Addendum
' (Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
4 4"",; +,t ' .14 .11 1 ��µ: `:rr{sw r rrv..a '. ki
ht.-
+ ₹ a a 1 t, y, E%2.y:,.-..,, r.1 M :11;111.414' 3:.. TM� c 'v.
,t.1*°' 3, iit"�"'' 'TM. �c' y v a�`, -t4 's �. 430 ' u ,�t {: ..........5g .. • '1413.C# .' B r :;mts as r ..Y.. t > v as
f` 3 }t '�A§e!-1�� ,iS 1L.:r'"f VY �.ySF£'a§�r�.o-"'' v9� �(.....t..;....
4 } ryp
s.e t M ew. tatr.,45:". •. ..kipx, c M keefi x
Age 0-10...$16.32 '' `§4
($496) Basic Maint $4.93 day/$150mo ^>f Level 0 $0 .,.„
County Age 11-14...$18.0Ca 5 Therapy not needed or provided •::t.:.
Basic ($549) No crisis intervention,Minimal CPA ,aa1 by .,ze+ Level 0...$0
Masi Age 15-21...$19.27 ,...s.(4,' (None)
($586) involvement,one face-to-face visit aLa another source,i.e.mental health.
if +$.66 Respite Care tIlk 6 w'
($20) x. with child per month.
$19.73 Level 1 $8.22 day/$250 mo t44 Level 1 $4.93/$150 mo '...^...-4.44
1 +$.66 Respite Care a Minimal crisis intervention as needed, r„,i Regularly scheduled therapy,
v. one face-to-face visit per month withs Level 1 ...$2.99
41.'Le ($20.39 day/$620 mo) � child, ". up to 4 hours/month.
2-3 contacts per month +;>
''. $23.01 1'Iv
1 1/2 - +$.66 Respite Care ) Level 1 1/2 $9.86 day/$300 mo /,....,, ---------- r
r xm ($23.67 day/$720 mo) z�+ . ?;
lat $26.30 0^"' Level 2 $11.51 day/$350 mo '.'..,..4,;,:
Level 2 $9.86/$300 mo `4 .
2 +$.66 Respite Care Occasional crisis intervention as needed, 4,41r, Weekly scheduled therapy, • •' Level 2..$4.47
•f two face-to-face visits with child, 9:•,... 5-8 hours a month with 4 hours of '„`
($26.96 day/$820 mo) v
2-3 contacts per month ; group therapy.
Mk skst $29.59 '1:?
441
21/2 +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo c` xo-; --------
($30.25 day/$920 mo) • ..+'
lik $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
w,, $ Level 3..$6.02
t weekly face-to-face visits with child, (;,,,x4., more
($33.54day/$1020 mo) and intensive coordination of e,�
44 NM . -:: than 1 person, i.e.family therapy,
6-14 141 y
k multiple services. x._' for 9-12 hours/monthly. a
$36.16
3 1/2 +$.66 Respite Care Z' , Level 3 1/2 $16.44 day/$500 mo � $'
:. ------TA
-- -
($36.82 day/$1,120 mo)
axe
Si$ $39.45 :4%4: Level 4 $18.08 day/$550 mo :Wit.: Level 4 $14.79/$450 mo
Al a +$.66 Respite Care Ongoing crisis intervention as needed, ") Regularly scheduled weekly a
4 a multiple sessions,can include
TRCCF 4 which includes high level of case c.1 more
Level 4....Neg.
Drop Down pi ($40.11 day/$1220 mo) management and CPA involvement with .? than 1 person,i.e.family therapy, a''d 44
child and provider and 2-3 face to face ;.4, for 9-12 hours/monthly.
` 4 contacts •er week minimum. :i .
Assess/
Emergency $30.25 day/$920 mo e.,v
Level (Includes Respite) $13.15 day/$400 mo f n
Rate „ ( '
i. .3 '45 s,
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
•. . . n f
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
14
zM SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
' DEPARTMENT OF HUMAN
t SERVICES
1%61 c ),
/By: ' I,. '-v By: �1 fi
Dep "y Clerk to the Board , Cr
Is' Chair Signatur
--".2._. .--....2_
`'" A 2012
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Quality Life Services LLC
OF HUMAN SERVICES 11975 Reed Street
1O80020
By: d .
erector
Quality Life Service yyp,,
11975 Reed Street Suite 1
Broomfield,CO 80020
CO611)g c An f it r icoYik
c9&/a -0,769.
8 Weld County SS-23A Addendum
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