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Home My WebLink About20122752.tiff MEMORANDUM 1861. DATE: September 27, 2012 -`:--E '/ TO: Sean P. Conway, Chair, Board of County Commissioners v �( it //J, G O �N T FROM: Judy A. Griego, Director, Human Strvicds 1)epaf'tintnf RE: Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements and the Weld County Addendums to the Agreements between the Weld County Department of Human Services and Various Providers for Consent Agenda Enclosed for Board approval are Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements and the Weld County Addendums to the Agreements between the Department and Various Providers. These Agreements were reviewed under the Board's Pass-Around Memorandum dated June 13, 2012, and approved for placement on the Board's Consent Agenda. The major provisions for these Agreements are as follows: No. Provider/Term Facility Type/Location Daily Rate 1 Almond, Earl and Cindy Foster Home $16.32-$40.11 July 1, 2012 —June 30, 2013 Johnstown, Colorado 2 Hernandez, Roberto and Margarita Foster Home $16.32-$40.11 July 1, 2012 — June 30, 2013 Fort Lupton, Colorado 3 Kniss, Kevin and Kelly Foster Home $16.32-$40.11 July 1, 2012—June 30, 2013 Thornton, Colorado 4 Pierce, Kris and Larry Foster Home $16.32-$40.11 July 1, 2012—June 30, 2013 Greeley, Colorado 5 Pluma, Mike and Annette Foster Home $16.32-$40.11 July 1, 2012— June 30, 2013 Kersey, Colorado 6 Shindle, Danny and Andrea Foster Home $16.32-$40.11 July 1, 2012—June 30, 2013 Greeley, Colorado 7 Wilbert, Melody D and Lee, Kimberly Foster Home $16.32-$40.11 July 1, 2012 —June 30, 2013 LaSalle, Colorado If you have questions, please give me a call at extension 6510. //2012-2752 lx�7/e 12x3 tie iL v.E/2-t GCz. L,L4sci LWS-/H(KIU-10/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND • FOSTER CARE FACILITY AGREEMENT Peen JUL 2 1. THIS CONTRACT AND AGREEMENT, made this date, r\-U,T ,d-)9 ado/L by and between 12®1? the Board of Weld County Commissioners, sitting as the Boardof Social'Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department"and, Almond, Earl and Cindy, Provider ID#61603, 1000 Country Acres Dr., Johnstown, CO 80531, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2012 and continue in force until June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 CWJ-/A (KIU-IU/99) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 2 LWJ-/A(K1U-IU/99) 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County C rk to the T,°rf"~, WELD COUNTY BOARD OF SOCIAL )i it` LR(9 " SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN r�l HNyt ERVICES kr 1861 y,� '. is� .. 4�� yt t /at " I By: � � � _ � "By Depu Clerk to the Boar Chair Signature OCT O 1 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Almond, Earl and Cindy OF HUMAN SERVICES 1000 Country Acres Dr. Johnstown, CO 80531 By: & X ��( 760)o-- )o By: 0)4( 9 rect 's Sig ture/Date ,Provide ' Signature/Date By: Le,"' Provider's Signature/Date 3 . I WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care 4 Services and Foster Care Facility Agreement(the "Agreement") between I9 Almond, Earl and Cindy ed.'"r and the cP Weld County Department of Human Services '9 for the period from July 1, 2012 through June 30, 2013. '� Ay' At)) following provisions, made this () day of 1 , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#61603. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. q&O/ - c725 1 Weld County Addendum to the CWS-7A • C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Provider will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' 2 Weld County Addendum to the CWS-7A Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER SHALL: 1. Attend or participate, if requested by the Department, in staffing a child's placement with the Service Utilization Unit. Provider shall be notified by County staff of the date and time of the review. 2. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 4. Have physical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 7. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; 3 Weld County Addendum to the CWS-7A • violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local)terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week ❑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 Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required DI)Once a month ❑1'/)Two times month 02)Three times a month 02%)Once a week 03)Two times a week ❑3'/:)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a''/3 hour per day 01%) 1/2 hour a day 02) I hour a day 02 /) I1/2-2 hours per day 03)2'/2-3 hours per day ❑3'/)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? O 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%) I I to 14 hours per week ❑3)Constant basis during awake hours ❑3'/)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with 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 ❑3%)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) DI)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A • (Exhibit B) . WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that as sly to this child. ti , , , (,C `-.., ,.E ;i. h```ut ..F 4p �I F d-P y 16•• i ttt At . u ,I aa:€:: t n... ::. iti zc Aggression/Cruelty to Animals ❑ 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 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 ❑ 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behaviodmtensit of conditions which create the need for services that a..l to this child d .F /� siih� x 1 t 1.A • §' 1Z0 t i u i 144 it§. xf 1 t a 45. r t? Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ ❑ 0 0 ❑ ❑ ❑ Depressive-like Behavior ❑ 0 0 0 0 0 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 0 0 0 Boundary Issues ❑ 0 0 ❑ 0 0 0 Requires Night Care ❑ ❑ ❑ 0 0 0 0 Education ❑ ❑ 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 ❑ El CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1 Yz ❑ 2 ❑ 2'/z Ill NEED ❑ 3 Yz Weld County Addendum to the CWS'J (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE gibl'Fir4444.7-awfkrwairtrasycs Ha tit -OA tiarafrit pp��,, � P$ ��it't`vT .k ,64s 1 a i�_ ,�AlaitiitagiaaltAge 0-10...$16.32/day ($496/month) County Basic v Age 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care '..'.h Total Rate= ($20.39 day/$620 month) $23.01 7 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 - +$.66 Respite Care Total Rate=($26.96 day/$820 month) `i $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 31/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) tta $39.45 4 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to t WELD COUNTY BOARD OF SOCIAL pyaa, SERVICES, ON BEHALF OF THE WELD fi�.. COUNTY DEPARTMENT OF HUMAN ° ' c ERVICES ISfiI tl%\till" By: k; e �3 /, / �' ' y. ' (J �' B Deputy erk to the Boar . 1 -� B Chair Signature OCT 0 1 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Almond, Earl and Cindy OF HUMAN SERVICES 1000 Country Acres Dr. Johnstown, CO 80531 BY ( ?C cr ) '7 9-7 t9- BY: ( t _ /s2/v2_ unty irect44/fiI's SI nature/Date Provider's Signature/Date � B • C Nz Provi 's Signature/Date &O/c2-&25: 9 Weld County Addendum to the CWS-7A S-7A LWS-/A (KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES • AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, _>yin `/ „<0/-2 by and between the Board of Weld County Commissioners, sitting as the Board of Soda' Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Hernandez, Roberto and Margarita, Provider ID#1520297, 912 Elm Ct, Fort Lupton, CO 80621, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2012 and continue in force until June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 LWS-/A(KIU-IU/99) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 2 LWS-/A(KIU-IU/99) '5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. • To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to the Bo, //�� WELD COUNTY BOARD OF SOCIAL ELD 4% SERVICES, COUNTY DEPARTMENT OF HUMAN ' / SERVICES Qt2 p By: •/ /Jlets �� By c� Deputy • erk to the Bot" / _ s Chair Signature OCT«a` ../ ZU12 .r .- Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hernandez, Roberto and Margarita OF HUMAN SERVICES 912 Elm Ct Fort Lupton, CO 80621 1,{(b)(4 ector' ,Sign re/Date r %ldSignatE/Date BY /�aX/'o�/La P%vider's S' nature/Dat 3 a©/a- d 95a WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Hernandez, Roberto and Margarita and the Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made this 7 day of /\ys , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1520297. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. &t/o?- 4 75°- Weld County Addendum to the CWS-7A C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Provider will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' 2 Weld County Addendum to the CWS-7A S-7A Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER SHALL: 1.• Attend or participate, if requested by the Department, in staffing a child's placement with the Service Utilization Unit. Provider shall be notified by County staff of the date and time of the review. 2. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 4. Have physical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 7. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; 3 Weld County Addendum to the CWS-7A violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week ❑1)One round trip a week ❑1'/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 Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month ❑1'/z)Two times month ❑2)Three times a month ❑2'/z)Once a week 03)Two times a week ❑3'/z)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular of special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a''/z hour per day 01%) 1/2 hour a day 02) I hour a day 02 '/z) 1'/,-2 hours per day 03)2'/z-3 hours per day ❑3%z)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%z) I Ito 14 hours per week ❑3)Constant basis during awake hours ❑3'/z)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond aee appropriate needs with feedin bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/:)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) 1 I to 15 hours per week ❑3) 16 to 20 per week ❑3%z)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑I) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. ❑2) Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO)Not needed or provided by another source(i.e. Medicaid) 01)Less than 4 hours per month ❑2)4-8 hours per month 03)9-12 hours per month 5 Weld County Addendum to the CWS-i (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/mtenstt of conditions which create the need for services that a,'I to this child. v A wr !l r� it�l: �n,..t text �.� �^+ a; �.l� � &.E i �t a �'�'�vrv,�s 'y'*'�`t m.,.' 3�� '�: x+ ! ant t`B: iip Con L * *s 3. 'NM` s" }"r ,4m a r m r r"a +�v @tl'i&b L'YlCg a ,tu 4v " w t a w f ry .n -rat a , itiZP H,s-'a Y. " im !y -64: r ° v! to t r'i,,,Y y nasp { a St tuS 8 .1 ,m {! !'�: t ip a $ luf 'Alt!c i t 2lire— { �t a - t 4, 4110441414-4144. l z " !e �T� -' a i*-i s S . , .. �''`w_' _�'5m-- ..1' 6w y.. 4.[_ .: �:. ;;!!pp Aggression/Cruelty to Animals 0 0 0 0 0 ❑ 0 Verbal or Physical Threatening 0 ❑ ❑ ❑ 0 ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 ❑ 6 Weld County Addendum to the CWS-7 S-7 (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that apply to this child a•'�:441,: i�I' 1 v l" 3 s Y £4-"u�g of Con -`s.y ar e' n S i r a4"i t,e y"F t`+ =r,.x, aif fib .. I'i j r : ea "sx a e e f p,,,, , u a �' H' v t5 u ?r~1 ra ;%ti i�Ft i w Y1 '!, L i 4 a ga G i i <_ ,^ lr . �" p. irci6..' ..; al. icii i✓ �r-'r W *i0;;;ki shy tc �• c e$ i s '� ₹ .� f r s r is x aiyUP A1 "'ma- : $.,.} x�rt ��'+`y�-,a��RaE y � �p '��i s�., rc` 0 >3r°y 'via�� h vSl�` '�' v }♦ .( o A3� , trams xu =l. 63r � ,5 � ` S i wl� .: ,: '� t ��4.3N -a3 �rifrll� �{N r a �-,�a d Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ O O O Disruptive Behavior ❑ O O O O O O Delinquent Behavior ❑ O ❑ O O O ❑ Depressive-like Behavior ❑ O O O O O O Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ O O O O Eating Problems ❑ ❑ O O O O O Boundary Issues ❑ O O ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family O ❑ ❑ O ❑ O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑i ❑ P/ ❑ 2 ❑ 2''/ ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CW S-: (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE EiMitikiLt Orrtti J r,{ ! SF�i5h �.�. , i r2 4k� R 5.4 .i 6 �i r 61 -�!,Y�1` �i > 41i � i 3Fy4.a !.f igN ₹x u t,i - x` panA. -a�.+'!S`'iL`>.a �` 'it�.11i?i -S 56 va i gainika j nvd u k� ' &mom" -4L s i C r `,44 .v-. " a 0 lii fr� i4 � L-!a i�tii W! 3 + Ga'S --T k ' r 3:41414144%141111,1444444444 e 4t 1144 14141444114414111O444.,41! 4 1 Y444.4444444444,44444444444 S444444a4404444444..5 µµ R ... .: Age 0-10...$16.32/day ($496/month) 4.O County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 }. 4.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care ! Total Rate=($23.67 day/$720 month) VliEp $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$.66 Respite Care ? Total Rate=($30.25 day/$920 month) $32.88 3 4.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 31/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) • 10 If Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-1 • 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 SERV , ON H O TE �� COUNTYICES DEPARTMENTBEALF OFF HUMAN SERVICES b BY: 7 �Cttv y: Deput Jerk to the B c , �rdv` r // Chair Signature OCT zoiz Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hernandez, Roberto and Margarita OF HUMAN SERVICES 912 Elm Ct Fort Lupton, CO 80621 BY .4 �) ,3 ))3Ol&- By: untyibirect 's Si ature/Date Provide s Signature/Date By: ProIder's Signature/Dat &O/&— 25<cl 9 Weld County Addendum to the CWS-7A L W J-/A(K I U-I U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY �AGREEMENT /I 1. THIS CONTRACT AND AGREEMENT, made this date, / a29,0702 by and between the Board of Weld County Commissioners, sitting as the Boar f Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Kniss, Kevin and Kelly, Provider ID#1524303, 13089 Marion Dr., Thornton, CO 80241-1936, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2012 and continue in force until June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 &O/&-a 76 LWJ-/A(KIU-W199) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 2 I.WJ-/A (KIU-IU/99) 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk tot �l r WELD COUNTY BOARD OF SOCIAL ,/i Qi e 'N\ SERVICES, ON BEHALF OF THE WELD b ; - ,), , COUNTY DEPARTMENT OF HUMAN / ,},137is. tl, SERVICES as 'C l.� Ll By: 1�i� is �ie17II�i:a'r; `A./ By: �� P �� Deput clerk to the Bo W'. -' t`? y-/ Chair Signature (--).''Lt- 0CT 01-2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Kniss, Kevin and Kelly OF HUMAN SERVICES 13089 Marion Dr. ' Thornton, CO 80241-1936 BY:,_ j(�( 14 ( LVO 1 I-7h/3- By: -. Qi ct is ignat a/Date Provider's Signature/Date By./-44,—„<-2/c17-e--)H4- -7/ J//o1 vi9er's Signature/Date 3 CJ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Kniss, Kevin and Kelly and the Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made this 029day of /4(.444 , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of t1Ye Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1524303. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. O7O/O7— &2' Weld County Addendum to the CWS-7A C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Provider will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s)to the Human Services' 2 Weld County Addendum to the CWS-7A S-7A Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER SHALL: 1. Attend or participate, if requested by the Department, in staffing a child's placement with the Service Utilization Unit. Provider shall be notified by County staff of the date and time of the review. 2. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 4. Have physical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 7. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; 3 Weld County Addendum to the CWS-7A violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑1)One round trip a week 011/4)2 round trips a week 02)3-4 round trips a week. ❑2/)5 round trips a week 03)6 round trips a week 03%) 7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? O Basic Maint.)No participation required 01)Once a month ❑1%z)Two times month 02)Three times a month ❑2'/z)Once a week 03)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements 01) Less than a '/z hour per day 011/4) 1/4 hour a day ❑2) 1 hour a day 02 %z) 1'/z-2 hours per day 03)2'h-3 hours per day ❑3/) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/) I I to 14 hours per week ❑3)Constant basis during awake hours ❑3'/:)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? O Basic Maint.)0-2 hours per week 01)3 to 4 hours per week 011/2)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/z) II to 15 hours per week ❑3) 16 to 20 per week ❑3''/)21 or more hours per week Comments: A I. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) DI) Face-to-face contact one time per month with child and minimal crisis intervention. ❑I%z) Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/z) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/z) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) DI) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. '� t i +x h.y t "Nir l rsi". rs E yx isc 3 pa u. �" . i ,fa 431;:',004 vl. y d. .-:',.7:- ,a.. ti ".'4 .,, v .� t u : : t �arl evs t { a -..i.,...4:14 n , .� tit Aggression/Cruelty to Animals ❑ ❑ 0 0 0 0 0 Verbal or Physical Threatening 0 0 ❑ ❑ 0 0 0 Destructive of Property/Fire Setting 0 0 El ❑ 0 ❑ ❑ Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 El 0 0 0 Runaway O 0 ❑ 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7 ' (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intenslt?,of conditions which create the need for services that apply to this child. _} 1 lie !' �! 's' R4nF ??3k d ..F 'i l: 'ti t f Aa ss°° I 1 I x *Eda E . Rating of Condition a� � R gr�c 2. '� Fss,' r X d6 '. .f g:k is - ". � ��y �' ' 't ` one nt each.category)x tett s e ,r ::' ,r _ r o- s s ,�'% r "-Alf+t`u ,R k t-rw t efl., ,� a r-- r i 1�*� ..�ra.� s,.., . s 4 Ai�.Wp33ll� t 1r y t dm a,ro + h a d �' )1041111,S .11mmwMk v 'lit u)n i�'''' n 1'c 4,1 a - �' `r `rri l....-Ate` I , t.4i 1t2 . 2 2� y r . 9 I.... s, �,r- r� .-...iii �4t'i w.w r.t�t�_°. r z , .. . a..' Inappropriate Sexual Behavior ❑ O O ❑ ❑ O O Disruptive Behavior El O O O ❑ ❑ ❑ Delinquent Behavior ❑ O O ❑ ❑ ❑ O Depressive-like Behavior ❑ O O ❑ O O O Medical Needs (II'condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ O ❑ ❑ ❑ O Boundary Issues ❑ O ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ O ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑i ❑ 1'A ❑ 2 ❑ 2''/ ❑ 3 ❑ 3'/z 7 Weld County Addendum to the C W S= (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE s t . t r �' CaN R ''kl A4 y- 14 l P �y PP 0 }I u_� q- ea 3 1n.. .r.�, e t' }/5 y, L. ari '� r uw I ' sqiE a� it • a o-i t3A ttitt y'a'#° - ,.x tt,k;,. #" icx _.- s vary,. '>fi e� t d7Jt° tt Age 0-10...$16.32/day ($496/month) County Basic ,r Age 11-14...$16.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) rs $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 4.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$,66 Respite Care Total Rate=($33.54day/$1020 month) ittit Ittt $36.16 3 1/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) tali Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS- IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the B. WELD COUNTY BOARD OF SOCIAL ft 7. SERVICES, ON BEHALF OF THE WELD ci'' %COUNTY DEPARTMENT OF HUMAN ERVICES .1861 � !r �-' By L�I� i I :� t✓ y: Deputy 'erk to the Bo. . Chair Signature OCT O Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Kniss, Kevin and Kelly OF HUMAN SERVICES 13089 Marion Dr. Thornton, CO 80241-1936 By:44 it /tl�(�,,�1 " l/) D° By: L.- _ 7- CIL41Y unty�F irector 1 Sign .ure/Date Provider's Signature/Date Byi ' o der's ignat l ate a&O/c?— a2, 9 Weld County Addendum to the CWS-7A (-WJ-/A (KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 2\)(LixA ;J'. ,by and between the Board of Weld County Commissioners, sitting as the Boarfi of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Pierce, Kris and Larry, Provider ID#1586620, 3017 54th Ave, Greeley CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2012 and continue in force until June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 &O/a— 77s; • 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 2 LW -/A(K I V-10/99) 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County C rk to the WELD COUNTY BOARD OF SOCIAL `10 SERVICES, ON BEHALF OF THE WELD OUNTY DEPARTMENT OF HUMAN � ERVICES By: 2- fle y By. Deputy' Jerk to the Boar . ' ; ;' >� Chair Signature OCT 12 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pierce, Kris and Larry OF HUMAN SERVICES 3017 54th Ave Greeley CO 80634 By: R C 137�I� By: Ate Ce irector' Signae/Date ovider's Signature/ to By: Provider's S nature/Date 3 ?t/& 0225 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Pierce, Kris and Larry and the Weld County Department of Human Services for the period from July 1,2012 through June 30,2013. The following provisions, made this 7 day of ` , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1586620. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator,prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. c2Y/0i-O2 2.5. Weld County Addendum to the CWS-7A C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Provider will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' 2 Weld County Addendum to the CWS-7A Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER SHALL: 1. Attend or participate, if requested by the Department, in staffing a child's placement with the Service Utilization Unit. Provider shall be notified by County staff of the date and time of the review. 2. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 4. Have physical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 7. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; 3 Weld County Addendum to the CWS-7A violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local)terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (Exhibit B) ' WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? asic 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. O2%) 5 round trips a week O3)6 round trips a week O3%)7 round trips or more Comments: P 2. How o ten 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 O2)Three times a month O2%)Once a week O3)Two times a week O3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or specta education plan? Basic Maint.)No educational requirements ❑l)Less than a'%hour per day ❑1%)'/ hour a day O2) 1 hour a day O2 %) 1'/:-2 hours per day O3)2/-3 hours per day O3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or ctivities and/or crisis management? Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'/s) II to 14 hours per week 0 3)Constant basis during awake hours O3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? Ll^��aassic 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 ❑3'A)21 or more hours per week Comments: A 1. How of n is CPA/County case management required?(Does not include therapy) asic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 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. 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? U0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that as.l to this child. yt B P: 5a 1 $ p . t+ q } $5f �4k..t��33„. ..... ,.�. ...0..x ... .+.w... +x5':. , 4.`^, c.....n_ m"d°p.!.�..: wuu...at.. . . j .. ' . .. ...... Aggression/Cruelty to - Animals L, ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical �, / Threatening II 0 0 0 0 0 ❑ Destructive of Property/Fire Setting ❑/ 0 0 0 0 0 0 Stealing V 0 0 0 0 0 0 Self-injurious Behavior IV 0 0 0 0 0 0 Substance Abuse / lid ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions V 0 ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis / LAS 0 0 0 0 0 0 Runaway lE 0 0 0 0 0 0 Sexual Offenses 0 0 0 0 0 0 6 Weld County Addendum to the CWS- (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child. J _ t $,P. fi ..... .... ...... Inappropriate Sexual Behavior M ❑ 0 ❑ ❑ 0 0 Disruptive Behavior r 0 0 0 0 0 ❑ Delinquent Behavior U7 ❑ 0 0 ❑ ❑ ❑ Depressive-like Behavior ID/ ❑ 0 0 0 0 ❑ Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation 0 V ❑ 0 ❑ ❑ ❑ Eating Problems V ❑ ❑ ❑ ❑ ❑ 0 Boundary Issues V ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ 0 ❑ ❑ 0 Education - rV ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's / Family td ❑ ❑ ❑ ❑ 0 ❑ CHILD'S OVERALL LEVEL OF ED FROM BEHAVIOR ASSESSMENT: (check level of need) I- 2 1C ET1%2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'/ 7 Weld County Addendum to the CWS-7A • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE s F r•w p j u fi r.. i rz5 G. Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) �t7 $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care �rc. Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care 4,44 Total Rate=($33.54day/$1020 month) $36.16 3 1/2 gai +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down 4.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency j $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7A • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the B and WELD COUNTY BOARD OF SOCIAL Ea SERVICES, ON BEHALF OF THE WELD �^ �� COUNTY DEPARTMENT OF HUMAN • SERVICES 61 V, 1/42 By: iGGZ By: P Deputy erk to the tti Chair Signature OCT 01 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pierce, Kris and Larry OF HUMAN SERVICES 3017 54th Ave./ � Greeley, CO 80634 BY: 4 (tf 1 (4./20A9�t A I By: 7� a• t�al Co unt Dirin ure/Date ovider's Signature/Date By: p Provider's ignature/Date &O/ 2- (225,5 9 Weld County Addendum to the CWS-7A LWJ-/A(KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7/lam//hby and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Pluma, Mike and Annette, Provider ID135126, PO Box 34, Kersey, CO 80644, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2012 and continue in force until June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 a3aa7sa LWJ-/A (KIU-IU/9Y) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 2 L W S-/A(K I U-I U/YY) 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. • To involve the provider in service planning for the child as part of the overall treatment team. 7, To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to the 1E, t WELD COUNTY BOARD OF SOCIAL ERVICES, ON BEHALF OF THE WELD ' 414),ksj OUNTY DEPARTMENT OF HUMAN 1161 L; R• VICES F By: 7� � Deputy erk to the Board r. r 1 ,- /By: 1� P y Chair Signature 0CT 0 1 2 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pluma, Mike and Annette OF HUMAN SERVICES PO Box 34 Kersey, CO 8Q64� By:. l � �/ vtQ�^ J I I F By:� f)262 Di r ctor's i nature ate "-' Provider's Signature/Date J By: Provider's Signature/Date 3 07e7a- 0275 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care do Services and Foster Care Facility Agreement (the "Agreement") between 1 Pluma, Mike and Annette c,, and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. 6 The following provisions, made this ZI day of 4 2012, are added to the referenced Agreement. Except as modified hereby, all terms of th Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#35126. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. Weld County Addendum to the CWS-7A C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Provider will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s)to the Human Services' 2 Weld County Addendum to the CWS-7A Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER SHALL: 1. Attend or participate, if requested by the Department, in staffing a child's placement with the Service Utilization Unit. Provider shall be notified by County staff of the date and time of the review. 2. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 4. Have physical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 7. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; 3 Weld County Addendum to the CWS-7A violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local)terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1/)2 round trips a week 02)3-4 round trips a week. ❑2%)5 round trips a week 03)6 round trips a week 03%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 0 Once a month ❑1'/:)Two times month 02)Three times a month 02%)Once a week 03)Two times a week 03%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a ''/z hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 %) 1'/,-2 hours per day 03)2'/r3 hours per day ❑3'/) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.)No special involvement needed 01) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) I I to 14 hours per week 0 3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/)5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%)21 or more hours per week Comments: A I. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/x) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) DI)Less than 4 hours per month 02)4-8 hours per month 03)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..I to this child. i F 04`7 3� st a S is i # va 4 ds ��... '4�re G: # t tip 1'4".. t a as q .>,.t ill, 411Q A "std}','„ XTh, F� s !'f q8 >fl, iA 4 t �p Of COO s?$' W x .E,x `,r :',..i.7. � rt r. 7-','..:_ . 4: R 4i,44 t 1 u i ( 4 a s x .y &#ILL"", 3 `I i '� -9i e • i r. 1 t e, r Ct'''' L. to rs ' 7 t ,e' r efs �: t to d zr lid�syxw r i z sd�t#'u n as "I! yn i...,..4-1,,.4.• # i .1,C; „.„4,44.S.. f 'i ryp '� yam. ::4”:i ,.....„4:-/-1/4 ➢n::t' 1 4S,?f6i�k upp �'�4 d ;DI t'v 2 tM W t. . .w.. - ...b ilte h .e fry # '}°.",.., �"'u a,`�� '-i '3 Aggression/Cruelty to Animals 0 0 0 0 0 0 0 Verbal or Physical Threatening ❑ ❑ ❑ El 0 El 0 Destructive of Property/Fire Setting ❑ ❑ ❑ El ❑ 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 ❑ 0 0 ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ 0 ❑ 0 0 6 Weld County Addendum to the CWS- (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intend of conditions which create the need for services that a..I to this child. . 's �F 'hv i-oaatisfs , Z., .,s.,PXscsa-ct , s ° ?i '% vy ss h,sa. r i iF₹ z d. <. .yL j R i f"`�' 'I� d �,v.yfi a bRattlargatI _ }`H ,3y�' 4.1i 3711i:,;461 4416 #eta 1,411s t s yVa • ak } aE itif e Ord} k"a atv - a t g_+gym. 5 �ki'f � � " m �°" -- . e» 'a�:'.�s aww1, yy alare c "5 '� ifirelAla t r ai e 9r .. i 7a r il*Rama gamaint iz °`y p� r< x ,ia ai. 1� al9 f° s ,i tde a p,' s° 1.,:-....i,7,,;:,1s I i x Zy u:s...,. .st .( 0.71 �..,.°isvNFt; .a .. „fi,-.'t R .r s :''e gilt* s�B-�i. s b i s s >f S: .., ..:n. _ kyir it a'y" e 11 'r !'a s .. Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 ❑ 0 Medical Needs (If condition is rated"severe', ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ ❑ ❑ 0 0 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 ❑ 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 2% ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 2 48 t` v t" x x t o a�.w c t - �a�w�i fiF�,7 :3M a z x vi `' w.t `i "�a�', s i} , IW Age 0-10...$16.32/day ($496/month) 444 County Basic I' Age 11-14...$18.05/day ($549/month) Maintenance«. Rate - Age 15-21...$19.27/day ($586/month) O° +Respite Care$.66/day ($20/month) 541 54 $19.73 1 - +$.66 Respite Care I RE Total Rate= ($20.39 day/$620 month) 454 415 54, $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1(2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) 414 $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1(2 +$.66 Respite Care .;,k Total Rate=($36.82 day/$1,120 month) $39.45 4 .54 +$.66 Respite Care TRCCF Drop Down Total Rate=($40.11 day/$1220 month) Assessment/Emergency 444 $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the : .: , WELD COUNTY BOARD OF SOCIAL . SERVICES, ON BEHALF OF THE WELD �' S COUNTY DEPARTMENT OF HUMAN ERVICES By: • , �4 Deputy Terk to the Bo i g` Chair Signature OCT 01 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pluma, Mike and Annette OF HUMAN SERVICES PO Box 34 ^ 4 /, Kersey, C 80644 2) a By:/ only )%rector's tgnatl /Date Pr Wider's Signature/Date Provider's Signature/Date go/a- 0775 9 Weld County Addendum to the CWS-7A S-7A (J W J-/A(IC I U-I U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 7m? A'' ?7 AM 1Ot I S 1. THIS CONTRACT AND AGREEMENT, made this date, by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Shindle, Danny and Andrea, Provider ID#1550177, 1561 41st Ave Ct, Greeley, CO 80634- 2758, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2012 and continue in force until June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 a©/a _a 75: CWS-/A(KIU-10/99) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 2 CANS-IA(1(10-1(1/T)) 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6' To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to the rF WELD COUNTY BOARD OF SOCIAL 1( 1( SERVICES, ON BEHALF OF THE WELD C.: COUNTY DEPARTMENT OF HUMAN IPZekf ERVICES / 1%61 ^ il °L7 By: yl By: Deputy erk to the Boar 1 Chair Signature OCT 01 2 12 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Shindle, Danny and Andrea OF HUMAN SERVICES 1561 41st Ave Ct Greeley, CO 80634-27 BY: Ailit ° /r ")) ),7/901'3 y: 72 i2 Dir tor's S jnatu /Date roerr''sSiignatuir /Date V By: � Provider's Signature/Date 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Shindle, Danny and Andrea and the Weld County Department of Human Services for the period from July 1, 2012 through June 30,2013. The following provisions, made this 1 O day of JJo I 2012, are added to the referenced Agreement. Except as modified hereby, all terms of t�ement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B. shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1550177. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4t" of each month following the month of service. If the reimbursement request is not submitted within twenty-five(25) calendar days of the month following service, it may result in forfeiture of payment. 0,90/07- 022` 1 Weld County Addendum to the CWS-7A C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Provider will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' 2 Weld County Addendum to the CWS-7A Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER SHALL: 1. Attend or participate, if requested by the Department, in staffing a child's placement with the Service Utilization Unit. Provider shall be notified by County staff of the date and time of the review. 2. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 4. Have physical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 7. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; 3 Weld County Addendum to the CWS-7A violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local)terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week ❑l)One round trip a week ❑1%z)2 round trips a week ❑2)3-4 round trips a week. ❑2'/i)5 round trips a week 03)6 round trips a week ❑3'/)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month ❑1/)Two times month ❑2)Three times a month ❑2%)Once a week 03)Two times a week ❑3'/:)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? 0 Basic Maint.)No educational requirements ❑1)Less than a ''/z hour per day DI v.) 'h hour a day ❑2) 1 hour a day 02 %z) 1'h-2 hours per day 03)21/4-3 hours per day ❑3'/z)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1%z)5 to 7 hours per week 02) 8 to 10 hours per week ❑2%z) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3%z)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding bathing,grooming, physical, and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 011/2)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 Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%z) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month 02)4-8 hours per month 03)9-12 hours per month 5 Weld County Addendum to the CWS-7, (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. "41\+.117: i - t st'. t . [ f r, t tiW:?�Mk mvoitt ;. �� "� si hi �$r , a u t7 i isa k s d,.`.,... u.,.`F'''''-'r-44. .t gp ,'s aim '� s d k. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ 0 Verbal or Physical Threatening ❑ ❑ 0 ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ID ❑ ❑ 0 0 ❑ Stealing ❑ ❑ ❑ ❑ ❑ ❑ 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ 0 ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ 0 ❑ ❑ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7/ (Exhibit B) WELD COUNTY OHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that ar rl to this child. t t t 2�u a fit an; ,& :ems a ;: # 14-1=7:4101:1-1:4,.:']d 3h s yli11, wry n +^r''� ylY t6q+,S.�`yb 1 Y x . s �q ' G {� 4 r 9 +A '} `§ 9 _xV .rt`I ^SY.`S "' � 6 -u � �!#. $E } T��r� �1 .} p W��y ; $. 'YPt R 5. $p$k pp : 3 f ;Ft Rt,F; 4 ° 3' §r^ "u *� y -� � 7rs 'star e 9Gtk lr'" d r E eb "tfy . -s �- '41-1', x,x {� x�Yh[L � s � h f e ki :;•� � r N p 4 `[ � �+ e �'3 r:12 thriblie4h,S'.1 � ,..i.. ,r suc.. k + .r.,,'=,.t 'r'..' a 74 ,' ,o M '� .«.$.� rt�'� , _ .�. t ,.. .Wit � . .ho Inappropriate Sexual Behavior 0 CI 0 0 0 ❑ Disruptive Behavior ❑ 0 0 ❑ ❑ ❑ 0 Delinquent Behavior ❑ ❑ ❑ 0 0 0 ❑ Depressive-like Behavior ❑ 0 0 ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe', ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 ❑ ❑ 0 ❑ Eating Problems ❑ ❑ ❑ 0 ❑ ❑ 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ El ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family CI CI CI CI CI CI CI CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 [Iii El 1% ❑ 2 III 2''/ III ❑ 3''/ 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Aii t.h ` i dyy 1 • Age 0-10...$16.32/day ($496/month) County Basic = Age 11-14...$18.05/day ($549/month) Maintenance Rate A.e 15-21...$19.27/da $586/month) +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care • Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care 6.17 Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 112 tof +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 g Weld County Addendum to the CWS- IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk t. ae.: . WELD COUNTY BOARD OF SOCIAL I ? SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN r O triNet SERVICES 1861 . 9 � A By. /.. / 1i �kki � �a„t By: . 2 Deput lerk to the B o ` ' Chair Signature 0CT 01 2012 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Shindle, Danny and Andrea OF HUMAN SERVICES 1561 41st Ave Ct Greeley, CO 80634-2758 By: td,t, G� G r� ai b7) A BY: unty Director' Signat e/Date Prod r' Signature/Date By: c Y'\('L�SZ --/CtUA .C 14 -70-0 f( rovider's Signature/Date aoia- a 20 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, ))v5J n(u-�il l /Z by and between the Board of Weld County Commissioners, sifting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Willert, Melody D and Lee, Kimberly, Provider ID#1540372, 219 N 4th St, LaSalle, CO 80645, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2012 and continue in force until June 30, 2013 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 LAWN-/A (K I U-I U/99) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 4. To give the provider a written record of the child's admission to the home at the time of placement. 2 LWJ-/A(KIU-10/99) I ! 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to the Bo ,�. WELD COUNTY BOARD OF SOCIAL :r l,,./) SERVICES, ON BEHALF OF THE WELD i t' / OUNTY DEPARTMENT OF HUMAN y�,4. `,.. . Q RVICES VW i ` I-- 'T' c By: fiTTDeputy Jerk to the Boar a Chair Signature OCT Z Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Willed, Melody D and Lee, Kimberly OF HUMAN SERVICES 219 N 4th St LaSalle, CO 80 BY )6JI, IlOr(); (111'3A))00- By: Dotl"J- Dire tor's Sie/ ate Provider's Signature/Date By: ' Provider's Signature/Date 3 0?oia- c2750? WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Willert, Melody D and Lee, Kimberly and the Weld County Department of Human Services for the period from July 1, 2012 through June 30, 2013. The following provisions, made this %. day of , 2012, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1540372. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. aoA?- a Weld County Addendum to the CWS-7A C. Placement service reimbursement shall be paid from the date of placement up to, • but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. If medical transportation is needed, Provider will arrange reimbursement through Medicaid. Any other special requests for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' 2 Weld County Addendum to the CWS-7A Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER SHALL: 1. Attend or participate, if requested by the Department, in staffing a child's placement with the Service Utilization Unit. Provider shall be notified by County staff of the date and time of the review. 2. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. Actively participate in achieving the child's permanency goal, cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate, and comply with the treatment plan of the child. 4. Have physical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 7. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; 3 Weld County Addendum to the CWS-7A violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (Exhibit B) , • , WELD COUNTY DNS ' NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P I. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1'/z)2 round trips a week 02)3-4 round trips a week. ❑2'/z)5 round trips a week 03)6 round trips a week ❑3%)7 round trips or more Comments: ) P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month ❑1%z)Two times month 02)Three times a month ❑2%z)Once(week 03)Two times a week ❑3'/z)Three times a week or more ,-\ Comments: P 3. How much time is the provider required to interve0e'rat home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educonal requirements ❑1) Less than a''/z hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %z) I'''A-2 hours per day 03)2'/z-3 hours per day ❑3'/x) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis man gement? ❑ Basic Maint.)No special inv vement needed ❑I)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 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week 02)8 to 10 hours per week 02%) I I to 15 hours per week ❑3) 16 to 20 per week ❑3%z)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'%)Face-to-face contact one timeper 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? 00)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) ' WELD COUNTY DHS ' NEEDS BASED CARE • BEHAVIOR ASSESSMENT Please rate th e behavior/intensit of conditions which create the need for services that a..I to this child. [ oy • t .: _ ` .I I. �`` mot* . i t1 _.„ °�.±�a,:. - s t 14— �.. .rT 11, y° s, 3av$F iy, •� M Aggression/Cruelty to Animals ❑ ❑ ❑ El 0 ❑ ❑ Verbal or Physical Threatening ❑ 0 0 ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ 0 ❑ ❑ ❑ ❑ ❑ Stealing ❑ 0 El ❑ ❑ 0 ❑ Self-injurious Behavior ❑ ❑ El El ❑ 0 0 Substance Abuse ❑ ❑ ❑ ❑ El El 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑ 0 0 0 Enuresis/Encopresis ❑ El 0 0 0 El 0 Runaway ❑ El ❑ ❑ 0 ❑ ❑ Sexual Offenses ❑ ❑ 0 El ❑ 0 El 6 Weld County Addendum to the CWS S (Exhibit B) • • ' WELD COUNTY DHS * NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED , Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. ;" 9 :, B d.51! :E t s,,,N if:, tik. :,� t , s*. q�n rc, .� ,4. ., 0 box for�1t ca a cliM a+a ..'L, .. ve ....` a.. . _ eu.A m kir i ..,_a- ... i - e,. .._ . , 'SW: ':t, 1..Val r uwo v( -...0.;U �M'1/4" {� v- xL a. L.� 3._:: 7'A tires : d ' � a. Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ O O O Delinquent Behavior ❑ ❑ O ❑ O O O Depressive-like Behavior ❑ ❑ O O O ❑ O Medical Needs (If condition is rated"severe", ❑ O O O O O 0 please complete the Medically fragile NBC) Emancipation ❑ O ❑ O O O O Eating Problems ❑ O O O O O O Boundary Issues ❑ ❑ O O O ❑ O Requires Night Care ❑ O O O O O O Education ❑ O O O O O O Involvement with Child's Family O O ❑ O O O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 2''/ ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS- (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE pK�,, 'i 1 d y, �.e � i�: . y A i .a kif. ts.`4 �s-t 'i � pa$' .. 0. 5 ". " Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate r;. Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 +$,66 Respite Care I p. Total Rate= ($20.39 day/$620 month) { $23.01 1 1/2 +$.66 Respite Care 1 Total Rate=($23.67 day/$720 month) $26.30 2 " " +$.66 Respite Care `N` Total Rate=($26.96 day/$820 month) 1 . $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 i +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 31/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 20 month(Includes Respite) 4 $39.45 TRCCF Drop Down +$66 Respite Care Total Rate=($40.11 day/$7220 month) Assessment/Emergency $30.25 day/$9 Rate Effective 7/1/2008 8 Weld County Addendum to the CWS- S- • SIN WITNESS WHEREOF,the parties hereto have duly executed the Addendum as of the day, month,and year first above written. ATTEST: Weld County Clerk to the te+ WELD COUNTY BOARD OF SOCIAL � p ) SERVICES,ON BEI!Ali'OF THE WELD �.t"'"'� • :. "� COUNTY DEPARTMENT OF HUMAN SERVICES Deputy .le to the lit $/ Chair Signature OCTO Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Willett,Melody D and Lee,Kimberly OF HUMAN SERVICES 219 N 4th St I'— LaSalle,CO 80645 °11 � y By: •rector's t r B^ Provider's t- St 13o�1�— rector's tgnal •clDate Provider'a SigwtutrlDate By: . ; y . __''j l2 , , Providet,'s Signature/Date tiara-0?7se 9 Weld Carty Addendum to df CWS-TA Hello