HomeMy WebLinkAbout20112539.tiff MEMORANDUM
1861 - 2011 DATE: September 22, 2011
TO: Barbara Kirkmeyer, Chair, Weld County Board of Commissi n ners
W E F D C O - T Y FROM: Judy A. Griego, Director, Human Services a
u ��
RE: Weld County Addendum to Purchase Child Placement Agency
Services between the Weld County Department of Human Services
and Various Providers to be Placed on the Consent Agenda
Enclosed for Board approval are Weld County Addendums to Purchase Child Placement Agency
Services between the Department and Various Providers. These Addendums were presented at the
Board's June 20, 2011, Work Session. Please place on the Consent Agenda.
Below are the major provisions of the attached Agreements:
No. Facility Name/Term Type of Facility/Location Daily Rate
1 Adoption Alliance Group Home/Foster Home $16.32-$40.11
July 1, 2011 —June 30, 2012 Denver, Colorado
2 Commonworks D.B.A. Synthesis Group Home/Foster Home $16.32-$40.11
July I, 2011 —June 30, 2012 Arvada, Colorado
3 Frontier Family Services Group Home/Foster Home $16.32-$40.11
July 1, 2011 —June 30, 2012 Longmont, Colorado
4 Hope & Family Group Home/Foster Home $16.32-$40.11
July 1, 2011 —June 30, 2012 Colorado Springs, Colorado
5 Lutheran Family Services of Group Home/Foster Home $16.32-$40.11
Colorado Fort Collins, Colorado
July 1, 2011 —June 30, 2012
6 Smith Agency Group Home/Foster Home $16.32-$40.11
July I, 2011 —June 30, 2012 Aurora, Colorado
If you have any questions, give me a call at extension 6510.
cOmpft// \ \ 2011-2539
, , WELD COUNTY ADDENDUM
•
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Adoption Alliance and Weld County Department
of Human Services for the period from
July 1, 2011 through June 30,2012.
The following provisions, made this / day of ��y , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the CPA identified as Provider ID#71259. 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. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
6. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
7. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
1 Weld County SS-23A Addendum
8;. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Contractor
shall be notified by County staff of the date and time of the review.
9. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County
Department of Social Services to shorten the duration of placement.
10. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
Contractor. All documentation of these examinations shall be forward to the County.
11. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized
Educational Plan (IEP) for youth designated as a Special Education Student every 3 years
and coordinate reviews every year. If the IEP is due while the child is in placement, the
Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to
the County.
12. Add Paragraph 18 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
14. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
2 Weld County SS-23A Addendum
1,5. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
16. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
17. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
18. Add Section VII -EXHIBITS:
3 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1''4)2 round trips a week
O2)3-4 round trips a week. ❑2'/)5 round trips a week O3)6 round trips a week
O3%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑l)Once a month ❑1%:)Two times month
O2)Three times a month ❑2'/n)Once a week O3)Two times a week
O3%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
O Basic Maint.)No educational requirements ❑1)Less than a '''A hour per day O11/2) 'A hour a day
❑2) 1 hour a day O2 'A) I'h-2 hours per day O3)2'A-3 hours per day
O3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week ❑1'/)5 to 7 hours per week
❑2)8 to 10 hours per week O2%) I I to 14 hours per week
❑3)Constant basis during awake hours ❑3'/:)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feedin
bathing,grooming,physical,and/or occupational therapy?
O Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week O11/2)5 to 7 hours per week
O2)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
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
O3'A)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addend,
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child.
',. •
h , t :1:•.12,,..:,
J ! p
f 2::•:,1::,,•••':.
r 11t
k c�,tyt+,Lt, ¢ fad ;i'••••,:---,.•11/41....7..t.: , Lt... . '':,�.; s::;•:.1.,.;.A.
't. . i.x.:' '�. . .. . Y ..,a: .,s+. , w'_ 3° h.t." ..Ja u°.:.... .� .•. .. ..... .. ,,, +;t.
Aggression/Cruelty to
Animals O O O O ❑ O O
Verbal or Physical
Threatening ❑ O O O O O O
Destructive of
Property/Fire Setting O O O O O O O
Stealing
❑ ❑ O O O O ❑
Self-injurious Behavior
❑ O O O O O ❑
Substance Abuse
❑ O O O O O O
Presence of Psychiatric
Symptoms/Conditions ❑ O ❑ O O O O
Enuresis/Encopresis
❑ ❑ O O O O O
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ O O O O O
5 Weld County SS-23A Addend'
(Exhibit B)
' . WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/Intense of conditions which create the need for services that al rl to this child.
3 "° r'v' gN j s �x `,v ' t a*. � a
ay. ...... . .... . _"' '1'2,..;:i.... ,:..i.:2,-.0.-3�."" s . • • rs.s :7₹rF . '^ v .. ' >s F..5;;yrP`, v 5 ~u0K-
! S_ � - 543: g. � -3.--..---
/ 3' •"*+.
.1AM : ..a-�x r... .., s ' R .^ .u. .., ati4+aa x`..eab:+. „r. a .:.,.. • . ..::,z:s ,k'i a.�'vs:e '..w:* a =.8...rra"ak x;'.,
Inappropriate Sexual
Behavior O O O O O O O
Disruptive Behavior
❑ O O O O O O
Delinquent Behavior
❑ O O O O ❑ O
Depressive-like Behavior
❑ ❑ ❑ ❑ O O O
Medical Needs
(If condition is rated"severe", O ❑ O O O O O
please complete the Medically
fragile NBC)
Emancipation
❑ O O O O O O
Eating Problems
❑ O O O O O O
Boundary Issues
❑ ❑ ❑ ❑ ❑ ❑ 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 O
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑l ❑ 1'/2 ❑ 2 ❑ 2% ❑ 3 ❑ 3''/
6 Weld County SS-23A Addends
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
s fir. S '( i � d ;9§k§ S } a•}
d' .14 s z ,4 sRr . v a t '"� m '. `,•i :
hit
•
+ ; Age 0-10...$16.32
($496) Basic Maint . $4.93 day/$150mo • Level 0 $0F.
County ; Age 11-14...$18.05 Therapy not needed or provided k,!.;!,.:,
Basic iv a#,41
($549) -e No crisis intervention,Minimal CPA sa •' by Level 0...$0
Maint. Age 15-21...$19.27 hit! (None)
'�' irqh
'
($586) s involvement,one face-to-face visit :+: another source,i.e.mental health.
+$.66 Respite Care - i
�, ($20) with child per month. .d
asC
$19.73 . Level 1 $8.22 day/$250 mo ot Level 1 947
$4.93/$150 mo
'j +$.66 Respite Care Minimal crisis intervention as needed, ' Regularly scheduled therapy, Level 1 ...$2.99
1
g one face-to-face visit per month with iLLi,
'`' child, e
disi ($20.39 day/$620 mo) up to 4 hours/month.
. 4
2-3 contacts per month cif
$23.01
44:44 Xi
11/2 1� +$.66 Respite Care . Level 11/2 $9.86 day/$300 mo .4„! ---------
($23.67 day/$720 mo)
$26.30 Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo
.'
2lir
+$.66 Respite Care Occasional crisis intervention as needed Weekly scheduled therapy, Level 2..$4.47
rata+ ($26.96 day/$820 mo) a two face-to-face visits with child, �.' 5-8 hours a month with 4 hours of
ital.`�. 2-3 contacts per month s.+4 group therapy.
;.
h $29.59 .%'� �;
2 1/2 4.66 Respite Care .: Level 2 1/2 $13.15 day/$400 mo ----- ------------
4441 ($30.25 day/$920 mo) g
•.. $32.88 " Level 3 $14.79 day/$450 mo r Level 3 $14.79/$450 mo Pp
ail- la
+$.66 Respite Care ' Ongoing crisis intervention as needed, Regularly scheduled weekly
ie: multiple sessions,can include64
3 r. Level 3..$6.02
weekly face-to-face visits with child, more
($33.54day/$1020 mo)
.i and intensive coordination of .+= than 1 person, i.e.family therapy,
multiple services. L;, for 9-12 hours/monthly.
.� $36.16 � . el
..
tlitz
3 1/2 '" +$.66 Respite Care - Level 3 1/2 $16.44 day/$500 mo 5uh
------____.---------
akt
NZ
($36.82 day/$1,120 mo) ` "
3f
gal $39.45 Level 4 $18.08 day/$550 mo a Level 4 $14.79/$450 mo 1.1
+$.66 Respite Care Ongoing crisis intervention as needed, .k, Regularly scheduled weekly
4 M: multiple sessions,can include
TRCCF • which includes high level of case more
Level 4....Neg.
Drop Down A= management and CPA involvement with ',: than 1person, i.e.family
to .; ($40.11 day/$1220 mo) 9 therapy,
child and provider and 2-3 face-to-face , . for 9-12 hours/monthly.
Mil
A
contacts 'er week minimum. a
Assess/
Emergency x $30.25 day/$920 mo kl:q
, „ $13.15 day/$400 mo
Level :% (Includes Respite) ` ,
Rate
Admin.Overhead Rate: As of 7/01/0E
$6.91 day/$210.00 month
7 Weld County SS-23A Addend
IN WITNESS WHEREOF,the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
s a OF THE WELD COUNTY
��r•�-�y, GJ I�``` '� DEPARTMENT OF HUMAN
SERVICES
isel
By: / :/. ►N_� / I `� B �L4 !i / Ci 6,Z( <.i
el
Depu. ler to the Board 1 � f � Chairignature
Approval as to Substance: CONTRACTOR °EP 2 6 2011
WELD COUNTY DEPARTMENT Adoption Alliance
OF HUMAN SERVICES 2121 S. Oneda St, Suite 420
Denver, O 80224
By: By: a
it ctor
8 Weld County SS-23A Addendum
•
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Commonworks D.B.A. Synthesis and Weld
County Department of Human Services for the period from
July 1,2011 through June 30, 2012.
The following provisions, made this / day of , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of th'Agreement remain unchanged.
I. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the CPA identified as Provider ID#104085. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. County and Contractor agree that for Children's Habilitation Residential Program
(CHRP) waiver eligible children, the County agrees to pay the federal SSI rate to
Contractor and all other service costs will be billable under the CHRP program.
4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
5. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
6. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
7. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
1 Weld County SS-23A Addendum
/ 537
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
9. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Contractor
shall be notified by County staff of the date and time of the review.
10. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County
Department of Social Services to shorten the duration of placement.
11. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
Contractor. All documentation of these examinations shall be forward to the County.
12. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized
Educational Plan(IEP) for youth designated as a Special Education Student every 3 years
and coordinate reviews every year. If the IEP is due while the child is in placement, the
Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to
the County.
13. Add Paragraph 18 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
14. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
15. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
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.
2 Weld County SS-23A Addendum
• 16. • Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
18. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term"litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
19. Add Section VII-EXHIBITS:
3 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# EX F ITRAILS CASE ID !DOB
WORKER COMPLETING ASSESSMENT HHN I IDATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.) Less than one round trip a week 01)One round trip a week 01%)2 round trips a week
❑2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week
O3%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑I)Once a month 01%)Two times month
❑2)Three times a month ❑2'/)Once a week O3)Two times a week
O3%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1) Less than a '/:hour per day 01%) '/z hour a day
O2) 1 hour a day O2 %) I'/-2 hours per day O3)2'/:-3 hours per day
O3%) More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑I) Less than 5 hours per week ❑1'/)5 to 7 hours per week
❑2)8 to 10 hours per week O2%) 11 to 14 hours per week
❑3)Constant basis during awake hours O3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond aee appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week
O3%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
O11/2) Face-to-face contact one time per month with child and occasional crisis intervention.
O2) Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3) Face-to-face contact weekly with child and occasional crisis intervention.
O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T I. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑l) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
•
(Exhibit B)
•
•
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a..l to this child.
2R,ksi i s 1 " iP i .s fit x c� *�u Y r a `*I x x �' a ., i 1 y Y r d .,
ry • Cud kt 4� t 1)
•.,141:19'4.:'da: . n '/•''''''2.''...
es a s "•,'''.',; ry x°j 3t h
Aggression/Cruelty to
Animals O O ❑ 0
❑ 0
0
Verbal or Physical
Threatening O O ❑ 0
❑ 0
0
Destructive of
Property/Fire Setting O O O O O O O
Stealing
❑ O O O O O O
Self-injurious Behavior
❑ O O O O O O
Substance Abuse
❑ O O O O O ❑
Presence of Psychiatric
Symptoms/Conditions ❑ O ❑ ❑ ❑ 0
❑
Enuresis/Encopresis
❑ O O O O O O
Runaway
❑ O O O O O O
Sexual Offenses
❑ O O O O O O
5 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensit of conditions which create the need for services that a..l z to this chid
,+'.4i4/0: 14:1:1-k7::::-''
� ,#5 p > °' v. > 'Y'..7 4f.'', i 4�&s1'4 ° ff,, . �� t° q: v k .Al tt.. ;''T is 1 M y I Ym _ I1 z 11:1/4°y`a`k r'' akag `.
g• f rs i} :,r R ° •},.Ir i. a. '` r a.a�y,y ;I a z a p x 3 0:1.541.41;1;04%%;$404-SE,
5 M'- G Q _
r';1",: �tx. .',7 ,. '71
r 'k f a,. � .,V a M ' .
gi
=r i. �, z s'4 'rv�..� t A -, . r 4 a+y .:a. 'f$ °a
....,-r.=; .,,.a,;;..�s.�.. _:.< , . ..:;,.,. �„�;.,.,�ra :a,r:'ec� �w..c�. s ��'�x .�.�, ' .:: xl • � � . * n2� �:
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ 0 0 0 0 0 0
Delinquent Behavior
❑ 0 0 0 0 0 0
Depressive-like Behavior
❑ 0 0 0 0 0 0
Medical Needs
(If condition is rated"severe", ❑ ❑ ❑ 0
❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
❑ 0 0 0 0 0 0
Eating Problems
❑ 0 0 0 0 0 0
Boundary Issues
❑ 0 0 0 0 0 0
Requires Night Care
❑ 0 0 0 0 0 0
Education
❑ 0 0 0 0 0 0
Involvement with Child's
Family 0 0 0 0 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'% ❑ 2 ❑ 2%z ❑ 3 ❑ 3%
6 Weld County SS-23A Addendum
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
'4E
45:fi� � .. � • • • • • ;" iniak�n rtrAp,rm v fa: d i'aitglii ,e r _ ,:::::.:;;;c6:',4
`:s espy�,a�a :
• $ ;Si"
PNYr'tiram:ir .u# Y ;r rrr.;Jr • :.. .., .,_ a .";:.c :.4f4.44,41-,4..,t :.. ,.44,_4„'.7.. & .a`a' 'x.
la Age 0-10...$16.32
($496) 1 Basic Maint $4.93 day/$15omo t„tt4 Level 0 $0
Coun Age 11-14...$18.05 i o- ` Therapy not needed or provided
tycfl
vy ($549) y No crisis intervention,Minimal CPA 3"'$ by
Bask Level 0...$0
Age 15-21...$19.27 "`v3
Maint. .; (None)
($586) involvement,one face-to-face visit yet another source,i.e.mental health.
tri +$.66 Respite Care -,a,fg Sit
it ($20) ' .' with child per month.
$19.73 ' Level 1 •$8.22 day/$250 mo f Level 1 $4.93/$150 mo
1 +$.66 Respite Care tt% Minimal crisis intervention as needed, ? Regularly scheduled therapy,
' one face-to-face visit per month with Level 1 ...$2.99
ittb ($20.39 day/$620 mo) h =. child, up to 4 hours/month.
„ari {:? 2-3 contacts per month : :
x $23.01
1 1/2 +$.66 Respite Care ,' Level 1 1/2 $9.86 day/$300 mo *-i -- _________
nS_:
I V ($23.67 day/$720 mo) ;.!".-1 t
Pi
$26.30 's Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 me
2 +$.66 Respite Care '« Occasional crisis intervention as needed, Weekly scheduled therapy,
q Level 2..$4.47
two face-to-face visits with child, 5-8 hours a month with 4 hours of
($26.96 day/$820 mo) fw .�
'4464/-'
2-3 contacts per month ''',1;-t.! group therapy.
pa $29.59
1?
2 1/2 +$.66 Respite Care a Level 2 1/2 $13.15 day/$400 mo AI
($30.25 day/$920 mo) Al * ;
$32.88 ' Level 3 $14.79 day/$450 mo it'll Level 3 $14.79/$450 mo
• +$.66 Respite Care s• 5 Ongoing crisis intervention as needed, �' Regularly scheduled weekly
3 w . .' multiple sessions,can include
w,';: weekly face-to-face visits with child, _t more Level 3..$6.02
($33.54day/$1020 mo) and intensive coordination of than 1 person, i.e.family therapy,
( t it t multiple services. for 9-12 hours/monthly.
$36.16 NIA iin
3 1/2 +$.66 Respite Care !rid. Level 3 1/2 $16.44 day/$500 mo
le ($36.82 day/$1,120 mo) t
$39.45 Level 4 $18.08 da /$550 mo
's y , , Level 4 $14.79/$450 mo i
+$.66 Respite Care Ongoing crisis intervention as needed„Pit Regularly scheduled weekly lipt,.'
Se a3
i.
4 : .5 multiple sessions,can include
„t
TRCCF :..44.. which includes high level of case more
r " Leve14....Neg.
Drop Down ($40.11 day/$1220 mo) „a management and CPA involvement with '.' than 1 person,i.e.family therapy,
10
§ provider hours/monthly.
and and 2-3 face-to-facelis for 9-12 hours/month) .
tat RI
tidi, contacts 'er week minimum. >,
Tu:
e
Assess/ i; V .1.
Emergency etti $30.25 day/$920 mo "
Level (Includes Respite) $13.15 day/$400 mo
":-4° X11::
Rate r' '-r il rk,
.,a+
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
Edda OF THE WELD COUNTY
J/ ♦ T, �� DEPARTMENT OF HUMAN
;D_�=; SERVICES i
Jul Ifs
By: %// / ,._ . './lip:I'/irrr �� j, B 4ILA, l tii%LG L
Depu. Clerk to the Boar ti."I Chair ignature
°EP 2 6 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Commonworks D.B.A. Synthesis
OF HUMAN SERVICES 5310 Ward Road, Suite G-01
Arvada,da/CO 8000, n2
By: BY: lam. DO0Is
Di ctor
aor/ 537
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Frontier Family Services and Weld County
Department of Human Services for the period from
July 1, 2011 through June 30, 2012.
The following provisions, made this ( day of l0`,4 , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the/Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the CPA identified as Provider ID#38041. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
6. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
7. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
&4//cQ53�
1 Weld County SS-23A Addendum
8. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Contractor
shall be notified by County staff of the date and time of the review.
9. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County
Department of Social Services to shorten the duration of placement.
10. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
Contractor. All documentation of these examinations shall be forward to the County.
11. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized
Educational Plan (IEP) for youth designated as a Special Education Student every 3 years
and coordinate reviews every year. If the IEP is due while the child is in placement, the
Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to
the County.
12. Add Paragraph 18 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
14. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
2 Weld County 55-23A Addendum
• 15. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
16. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
17. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
18. Add Section VII -EXHIBITS:
3 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# $EX F TRAILS CASE ID IDOB
I
WORKER COMPLETING ASSESSMENT HEM DATE OF ASSESSMENT
I
AGENCY NAME �1'ROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 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'/:)2 round trips a week
❑2)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week
❑3%:)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required 0 Once a month ❑1'/:)Two times month
02)Three times a month ❑2%)Once a week 03)Two times a week
03'A)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1) Less than a'/z hour per day 01%) 1/2 hour a day
02) I hour a day ❑2 %x) I'/,-2 hours per day 03)2'h-3 hours per day
❑3'/) More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week ❑1'/:)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'/a) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) I 1 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A I. How often is CPA/County case management required?(Does not include therapy)
['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%x)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.
O 3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T I. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensi of conditions which create the need for services that a..I to this child
��a� .-I,--,•;:h•-',L.„,-3� yli7.--;:l.i �y�?t �'y�'r7� ;,
' ;I:v.xm r " 'P1 .0 ;•.,„,•-,,, : R�.a'� t
...11"a1:. :-. .. . ,,,p' ',,rsz a° 4'-s° £ l r .. t..}.,,..•... '�s ip., °i3 i e
a�F e.886.a w,3.. '.T.- , ..,., ta'h4 w Lv�,e+
Aggression/Cruelty to
Animals O O O O O O O
Verbal or Physical
Threatening O O O O O O O
Destructive of
Property/Fire Setting O O O O O O O
Stealing
❑ O O O O O O
Self-injurious Behavior
❑ O O O O O O
Substance Abuse
❑ O O O O O O
Presence of Psychiatric
Symptoms/Conditions O O O O O O O
Enuresis/Encopresis
❑ O O O O ❑ O
Runaway
❑ O O O O O O
Sexual Offenses
❑ ❑ O O O O O
5 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensit of conditions which create the need for services that a..l to this child
y5a{( : .riMrowr r ' : wit h ' '" ry@ '"'t,- ;: rc :;f: " 'ir is
S � „ h� i • °a `444 W } tj{l� k � h 4 t'55 l
'`,'' `' `,, w YCi . .x . an f€r?„k x 4 r. *�.s 3° 5 %d t., ra ::r
. axe F�:datt9 e 7. ' s x '..-:2'+g y.yb
yh�k ' + ' tl i x ,aR'v' A e
i.
43^'+ .x 5 e.. .: '.;aNdx, dxl;;P;b :rvhv L4a..r t..' d'A `A,af . �S.3"' a SahF�
Inappropriate Sexual
Behavior O O O O O O O
Disruptive Behavior
❑ O O O O O O
Delinquent Behavior
❑ O O O O O O
Depressive-like Behavior
❑ O O O O O O
Medical Needs
(If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑please complete the Medically
fragile NBC)
Emancipation
❑ O O O O O O
Eating Problems
❑ O O O O O O
Boundary Issues
❑ O O 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 O
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑I ❑ 11/2 ❑ 2 ❑ 2''/ ❑ 3 ❑ 3'/z
6 Weld County SS-23A Addendum
a
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
,, .,,,,;••,;:•,7c,,,,!,::.1)::-.-: .� L `` ' het *•k vs • g';
Mite r t, ilv •:,i ' •,,'.':• A': f '7'.::':'4::::',4,41'410:E
'qk#�x .. .; qt . fi if 4 ::F:t1 *^ uk :4�,� .
7t S .. . . ...:a ;... .:z w xvr. x*hr4;;f;4 s..,;.:N._.J!!3.'L ii:fti1 v' W'. Y fix. x ....[»Y 4 $
Age 0-10. $16.32 w', s,a
h ($496) Basic Maint $4.93 day/$15omo r,-.:9 Level 0 $0
Vil
Age 11-14...$18.05
County �Yti } a: Therapy not needed or provided NYS
Basic ¢ ($549) s � No crisis intervention, Minimal CPA Ii4 by t,,," Level 0...$0
Mamt F Age 15-21...$19.27 : 4C!w (None)
($586) IS
involvement,one face-to-face visit o another source,i.e.mental health.
+$.66 Respite Care « 'IV:. ,e."
�" . $20 tS with child .er month. �''. •
_e
qA $19.73 Level 1 $8.22 day/$250 mo k*yz<- Level 1 $4.93/$150 mo 10
'r +$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy, SO
1 * „' one face-to-face visit per month with Level 1 ...$2.99
m, ($20.39 day/$620 mo) I ,. child, 4 up to 4 hours/month.
2-3 contacts .er month
$23.01 k1 .
1 1/2 �a F +$.66 Respite Care , ; Level 1 1/2 $9.86 day/$300 mo ',"': ----_ ---
$23.67 da /$720 mo s', Pa
--
$26.30 Level 2 $11.51 day/$350 mo rp,. Level 2 $9.86/$300 mo
2 +$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy, Level 2..$4.47
Pa
';}' ($26.96 day/$820 mo) two face-to-face visits with child, ti45-8 hours a month with 4 hours of fil kiA Fi
`tz',E 2-3 contacts .er month .rou. there.
+. . $29.59 P ri"t
2 1/2 +$.66 Respite Care ': Level 2 1/2 $13.15 day/$400 mo
($30.25 day/$920 mo)
wilr. YLi
PI
6 !
$32.88 a 1r4 Level 3 $14.79 day/$450 mo � Level 3 $14.79/$450 mo
Ws +$.66 Respite Care P� Ongoing crisis intervention as needed, Regularly scheduled weekly rb,
3 :: q multiple sessions,can include .
P ($33.54day/$1020 mo) .
weekly face-to-face visits with child, L'.w. more Level 3..$6.02
and intensive coordination of t than 1 person, i.e.family therapy, 10
ilsej
multiple services. r ,;. for 9-12 hours/monthl .
Na*;; $36.16 S.ry "yf
31/2 " +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo
E ($36.82day/$1,120mo)
Et
PA: Eila
* $39.45 1.4 Level 4 $18.08 day/$550 mo 414 Level 4.........$14.79/$450 mo
n.;. +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
4 + °v multiple sessions,can include
TRCCF which includes high level of case more -, Level 4.._Ne
Drop Down 10 a x?q sL tt. . 9'
($40.11 day/$1220 mo) -. management and CPA involvement with ",,,k‘
than 1 person, i.e.family therapy,
child and provider and 2-3 face-to face for 9-12 hours/monthly. tli
F.i
F
contacts 'er week minimum.
Assess/ F b3 , ,
Emergency .* $30.25 day/$920 mo $13.15 day/$400 mo
------—------------------ R.
Level (Includes Respite)
Rate
no
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
t ER,, Ma ILA N' DEPARTMENT OF HUMAN
tit lk - a
By: iI , ./eA.. 7" _/ B /; i6(
Deput 'lerk to the BoaryV Z j , ti\1 �` Chi Signatu
Approval as to Substance: CONTRACTOR CEP 2 6 2011
WELD COUNTY DEPARTMENT Frontier Family Services
OF HUMAN SERVICES 1290 Boston Ave
Longmont, CO 80501-5810
Di ctor
Oum 15y
$ Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Hope & Home and Weld County Department of
Human Services for the period from
July 1,2011 through June 30, 2012.
The following provisions, made this / day of ,77;j14 , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the CPA identified as Provider ID#29867. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
6. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
7. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
Weld County SS-23A Addendum
• 8. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Contractor
shall be notified by County staff of the date and time of the review.
9. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County
Department of Social Services to shorten the duration of placement.
10. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
Contractor. All documentation of these examinations shall be forward to the County.
11. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized
Educational Plan (IEP) for youth designated as a Special Education Student every 3 years
and coordinate reviews every year. If the IEP is due while the child is in placement, the
Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to
the County.
12. Add Paragraph 18 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
14. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
2 Weld County SS-23A Addendum
• 15. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
16. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
17. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
18. Add Section VII- EXHIBITS:
3 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX TRAILS CASE ID IDOB
F
WORKER COMPLETING ASSESSMENT IIH# M I DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week ❑I)One round trip a week O11/2)2 round trips a week
O2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week
❑3/)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month 01%)Two times month
O2)Three times a month ❑2%)Once a week O3)Two times a week
O3%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
O Basic Maint.)No educational requirements ❑1) Less than a '/:hour per day ❑1'%) '/:hour a day
❑2) I hour a day O2 '/) I'/:-2 hours per day O3)2'/:-3 hours per day
O3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed 01) Less than 5 hours per week ❑1%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'/:) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3'/)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming, physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑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
O3%)21 or more hours per week
A I. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
O11/2) Face-to-face contact one time per month with child and occasional crisis intervention.
O2) Face-to-face contact two times per month with child and occasional crisis intervention.
O2%) Face-to-face contact three times Der month with child and occasional crisis intervention.
O3) Face-to-face contact weekly with child and occasional crisis intervention.
O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month
O2)4-8 hours per month O3)9-12 hours per month
4 Weld County SS-23A Addendum
•
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensi of conditions which create the need for services that a..I to this child
'°w ! • • ' ii tt4 � "k �"+°rev
r.
' �< 3 xe 5 $;+ x aq t va s,�~r:•-• . 3�7
.T• c +uv,e uttrw L�s d"*i�.:�l.=w`aua, tw"$s�xYauth`� .o:
. . .,Y d
;;;...-"'l` s,� t # t
-7:nth z,s ia..' 9e 2 s 4 t �4u, d� r t _2,4 a t N
Aggression/Cruelty to
Animals O O O O O O O
Verbal or Physical
Threatening O ❑ ❑ O ❑ ❑ ❑
Destructive of
Property/Fire Setting O O O O O O O
Stealing
❑ O O O O O O
Self-injurious Behavior
❑ O O O O O O
Substance Abuse
❑ O O O O O O
Presence of Psychiatric
Symptoms/Conditions O O O O O O O
Enuresis/Encopresis
❑ O O O O O O
Runaway
❑ O O O O O O
Sexual Offenses
❑ O O O O O O
5 Weld County SS-23A Addendum
•
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child.
'w x f r ty xs + I r kite o-�a r�t t t ' i 3 x r.
T �z4 .r�'v ���Ak'}� ��f'��„ 5 ��
�Yis r r rht :3.p) rv'4 1.1. .ii{7 mrs' „ILS" �ff•r.•.
a*tai' 4 is ` °sYri..'# 'iig.%2 t e " SA 1q
1,1:4r;',— . ''.)1411,:!:!',-;:l.' .yy r .mu yyy,fi! i - u.s y p,.
k ivt%;\s'y • 2: t� x'k as 4 3. ,_ .. '` `. t ",-P" +p�:un
m .., . . e v.. i ,.... =. N +s e.:, .s°. '.. 04dashxte.'
Inappropriate Sexual
Behavior O O O O O O O
Disruptive Behavior
❑ O O O O O O
Delinquent Behavior
❑ O O O O O O
Depressive-like Behavior
❑ O O O O O O
Medical Needs
(If condition is rated"severe', ❑ ❑ ❑ ❑ ❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
❑ O O O O O O
Eating Problems
❑ O O O O O O
Boundary Issues
❑ O 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 ❑ 1'h ❑ 2 ❑ 2''/ ❑ 3 ❑ 3'%
6 Weld County SS-23A Addendum
•
(Exhibit C)
WELD COUNTY DEPARTMENT OF DUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
al'yk _ ₹ 44 u ,,I*, .e
's R ..� is c aIkIII �° n t r v.„
xs a i ";,,,,I.
`asu :a i <t agi.:
La AR *yd� r .i ,4;ANZ .y4.,
< : Age 0-10...$16.32 v,.
,oPiz-, ($496) Basic Maint $4.93 day/$150mo l ' Level 0 $0 kili
it
County i Age 11-14...$18.05 a ' Therapy not needed or providedrfaa
Basic ($549) No crisis intervention,Minimal CPA pit9 b • -
Maint. Sb I Age 15-21...$19.27 i if*1 None
($586) involvement,one face-to-face visit another source,i.e.mental health.
°4 +$.66 Respite Care ;:: I^s1 41
'
k
($20) ,FI. - with child per month.
i
k ,h $19.73 ` �. Level 1 $8.22 day/$250 mo ' Level 1 $4.93/$150 mo
Iu.
1 I, i +$.66 Respite Care �w Minimal crisis intervention as needed, ,; Regularly scheduled therapy,
' ' c one face-to-face visit per month with t. a Level 1 ...$2.99
xt- ($20.39 day/$620 mo) 2 lit?'child, i.,¢, up to 4 hours/month.
2-3 contacts per month •
'`> $23.01
1 1/2 +$.66 Respite Care I` i Level 1 1/2 $9.86 day/$300 mo l;,44 --------------------
reSI ($23.67 day/$720 mo) ! , I:
:;^: $26.30 ' Level 2 ;IIIII Int.
$11.51 day/$350 mo +' Level 2 $9.86/$300 mo fIlki
2 +$.66 Respite Care a Occasional crisis intervention as needed Weekly scheduled therapy,
Level 2..$4.47
"°f two face-to-face visits with child, 5-8 hours a month with 4 hours of
le CO($26.96 day/$820 mo) '+ 4
l :.`; 2-3 contacts per month group therapy. OP
:
$29.59 f2`;it
a is
2 1/2 � +$,66 Respite Care , Level 2 1/2 $13.15 day/$400 mo � '�
($30.25 day/$920 mo)
t
kTht
$32.88 Level 3 $14.79 day/$450 mo Level 3.........$14.79/$450 mo
+$.66 Respite Care ,,74 Ongoing crisis intervention as needed, VI Regularly scheduled weekly
3 r multiple sessions,can include Ikp
i
r ,' weekly face-to-face visits with child, ) i} more
a . Level 3..$6.02
($33.54day/$1020 mo) e�`" )
and intensive coordination of Ita than 1 person,i.e.family therapy, INS
fi=g;
PflIi :;;'.,1 multiple services. al for 9-12 hours/monthly. II
$36.16 )'. i2 hat
.3 1/2 +$.66 Respite Care , Level 3 1/2 $16.44 day/$500 mo
Vid;W' ($36.82 day/$1.120 mo) i £ :n
IRV
Ir. $39.45 , zit Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
y +$.66 Respite Care `:' Ongoing crisis intervention as needed, Regularly scheduled weekly
4 multiple sessions,can include
TRCCF which includes high level of case more
! $IIttl Level 4._.Neg.
Drop Down 44. ` management and CPA involvement with than 1person, i.e.family therapy,), ($40.11 day/$1220 mo) d ,., 9 �r
: child and provider and 2-3 face-to-face kj for 9-12 hours/monthly.
> :
contacts .er week minimum. It;a4
Assess/ .�x�: F '3
Emergency Wii. $30.25 day/$920 mo iiii $13.15 day/$400 mo --
Level ro , (Includes Respite) ' -
Ratev;: i
a 1F.
rid & 1i
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
Sid') OF THE WELD COUNTY
DEPARTMENT OF HUMAN
SERVICES
�
361
1,t t %�, i/itc�,j�
Depu'Clerk to the Boar Chair Chair ignature
SEP 2 6 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Hope & Home
OF HUMAN SERVICES 4945 N 30th Street, Suite 300
Colorado Springs, CO 80919-3152
By. Bye
Dir to
C
020//-, 7532
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Lutheran Family Services of Colorado and Weld
County Department of Human Services for the period from
July 1,2011 through June 30,2012.
The following provisions, made this_day of , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service,as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the CPA identified as Provider ID#45080. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Section I, Paragraph 4. Transportation may include, but is not limited to;visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
6. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests,plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County,prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
7. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
a0//-X555
1 Weld County SS-23A Addendum
8. Section III,Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Contractor
shall be notified by County staff of the date and time of the review.
9. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County
Department of Social Services to shorten the duration of placement.
10. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
Contractor. All documentation of these examinations shall be forward to the County.
11. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized
Educational Plan (IEP) for youth designated as a Special Education Student every 3 years
and coordinate reviews every year. If the IEP is due while the child is in placement,the
Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to
the County.
12. Add Paragraph 18 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred,suspended,proposed for debarment,and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not,within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records,making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state,or local) with commission of any of the offenses
enumerated in paragraph(B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions(federal, state, and local)terminated for cause or default.
13. Section V. Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
14. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees,and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
J Weld County SS-21A Addendum
15. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
16. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
17. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five(5)calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term"litigation" includes an
assignment for the benefit of creditors,and filings in bankruptcy, reorganizations and/or
foreclosure.
18. Add Section VII-EXHIBITS:
1 Weld("minty SS-71A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
IENTIFYING INFORMATION
HILD'S NAME STATE IWO $EX F 'TRAILS CASE ID !DOB
I'ORKER COMPLETING ASSESSMENT BMS PATE OF ASSESSMENT
GENCY NAME PROVIDER NAME PROVIDER TRAILS ID
NSWERS 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.
HE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
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 O1%)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
2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
0 Basic Maint.)No participation required ❑1)Once a month ❑1%)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
O3%)Three times a week or more
3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint)No educational requirements 01)Less than a%hour per day 01%)%,hour a day
❑2) 1 hour a day O2 %) 1'/,-2 hours per day O3)2%-3 hours per day
❑3''/)More that 3 hours per day
4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) I I to 14 hours per week
❑3)Constant basis during awake hours ❑3'/x)Nighttime hours
5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week O2%) I I to 15 hours per week ❑3) 16 to 20 per week
O3%)21 or more hours per week
1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times Der 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.
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
O2)4-8 hours per month O3)9-12 hours per month
4 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensi of conditions which create the need for services that a .I to this child.
,.t- C �.n% ',T. -4[0'[0 r , v i:r .. Y• r<+ a. 7rz
}� • - yy^'rR°i � it VICi7� 'a4�,''p� �'Si' n x,�..�
+,,Tk'st+t• 'L r aYl.fg F' 2 .'r„ forNeajb ca
� I I t G Jurr i�`
�" J• , 1 W ,fit 'led.' `F:i YKq r .:� ✓x,. fir _
it r r A7 r . �' ti r 4Y I
y� r .a.3. x������� yr y tat
. TIER;
Y .M � J � ,S IL,_ �� iii �t "� � 1 r-._ �tYYx1YY67tit. .
hill. J /r� .,,
... _ � . �r, �... 'Hi f L lllrCNi 1 i i`.
aka"' _. . . _. ,ter,.. ...
ggression/Cruelty to
nimals ❑ ❑ ❑ ❑ ❑ ❑ ❑
erbal or Physical
hreatening ❑ ❑ ❑ ❑ ❑ ❑ ❑
>estructive of
roperty/Fire Setting ❑ O ❑ O O ❑ O
tealing
❑ O O O O O ❑
elf-injurious Behavior
❑ O ❑ ❑ O O O
ubstance Abuse
O O ❑ ❑ O O O
resence of Psychiatric
ymptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑
nuresis/Encopresis
❑ O ❑ O O O ❑
unaway
❑ ❑ O O ❑ ❑ ❑
exual Offenses
❑ O ❑ O ❑ ❑ ❑
5 Weld County SS-23A Addendum
. (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that a rpl to this child.
�., ,. go 9. � f Cl�≥�t�on ilr -2,44" `
M1' ' ' t .1 yv�r.r nt In itr —m 7'i M1{+a v€ ✓ ' .S Vw 5 w.. ' r: ,
i Y•' A. '� 't� 1 1, • itin 01f6'�IOI fur l�Cll ' A$ al i a+'1 L k r
k gip. •- - •1 d 1 w. „12jw; > 1 ` �,'',ps
r YI i y l4a'liYt( 't�` i +r. T'f." xx J iMFNii
� Y I r r( k, q1. �
r
W�r,�!��r v- r�`°i Wc }�, ,v <
ti r+l) afk " mesa, i Fk'+4 b ht .e.. 'I
� � ' ' , : I. - ':Ryi'Ag, F ','' 112 2., • 21/ ': ' ''y,F w� ' v(c iUvF f
'appropriate Sexual
ehavior O O ❑ O O O O
lisruptive Behavior
❑ O O ❑ O ❑ ❑
'elinquent Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
repressive-like Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
tedical Needs
(If condition is rated"severe", El ❑ O ❑ ❑ ❑ ❑
please complete the Medically
fragile NBC)
mancipation
❑ ❑ ❑ ❑ O O O
ating Problems
❑ O ❑ ❑ O ❑ O
oundaryIssues
❑ ❑ ❑ ❑ ❑ ❑ ❑
equires Night Care
❑ ❑ O ❑ ❑ O O
ducation
❑ O O O O ❑ O
ivolvement with Child's
amily O ❑ ❑ O ❑ O ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) O 0 ❑1 n 1% n 2 n 2'/2 n 3 n 3'h
6 Weld County SS-23A Addendum
' (Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
*tit'
din, � s.. Iw; le +i LS, ri� 1 �AQ4 yro�„y t}�'xat 'ya a T;i. r.'-;� Zr - i SreY xh'!(t >°-+rl ,', r) / 7, t]r'" ;'?-1.;
�:RATE'(.t' :^ +�l' i -!s ;' _t k*k ui M
SE
( s!,1'.,
tr r , 1;1/4.;,w :7
8E n ! s ,,,•,,/:',", v. vi �"" 'A s{bit . Y =-:•0'.
i ry
i t.,4.- ii ti w,it oa i r r r'C Y t.�
in a�S't rr .l iC tf1 ikh t "a- < T
k �n _ y�t,qtr t b' q� ^d..
LsYel '" -4'.44.":14 :1C4..,C °' -.4 ` lei named ' 4 i " b 1 , " P - ' 1 --
• X +(xn ,j�'t I' ..: .. l" ,..-- . +S (� it 'Aral/...;.Y e
! + P °= " t � 13O-4.',/- ,v In.Maim) k�4 skLti�. Th.�f ' r1"� iz, w, C.`�. P_
A Age 0-10...$16.32 usi r �'' `
($498) g• Basic Maint $4.93 day/$150mo Level0 $0
Cou ,1 Age 11-14...$18.05 Therapy not needed or provided
Bas 1 ! ($549) it
;; No crisis Intervention,Minimal CPA 1. by
Maim. ,'( Age 15-21...$19.27
Ph ($586) ` involvement,one face-to-face visit 9 another source,i.e.mental health. .
. +$.66 Respite Care .4
_si ($20) with child per month. t"
$19.73 f: ''
Level 1 $8.22 day/3250 mo '' Level 1 $4.93/$150 mo
+$.66 Respite Care r,'.�i Minimal crisis intervention as needed, Regularly scheduled therapy,
1 ;)/;r one face-to-face visit per month with
1d
.
($20.39 day/$820 mo) *°,i;
child, up to 4 hours/month.
2-3 contacts per month £'w
t-' $23.01
1 1/2 , +5.66 Respite Care ; Level 1 1/2 $9.86 day/$300 mo
)? ($23.67 day/$720 mo) . .a a(
4
;444 $26.30 k, Level 2 $11.51 day/$350 mo S ' Level 2 59.86/5300 mo .
2 +5.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy,
($26.96 day/51120 mo) two face-to-face visits with child, 5-8 hours a month with 4 hours of
2-3 contacts per month group therapy.
$29.59 `
21/2 +5.66 Respite Care t Level 2 1/2.........$13.15 day/$400 mo ::
• ($30.25 day/$920 mo) .
$32.88 Y,,, Level 3 $14.79 day/$450 mo p s: Level 3 $14.79/$450 mo
;
;� +5.66 Respite Care I:; Ongoing crisis intervention as needed, a Regularly scheduled weekly
f,, multiple sessions,can include
3 C weekly face-to-face visits with child, ,,. more ,.
($33.54day/$1020 mo) and intensive coordination of than 1 person,i.e.family therapy,
') ,n. multiple services. for 9-12 hours/monthly.
F $38.18 i ,, - 7
3112 _ +$.66 Respite Care •"; Level 3 1/2 $16.44 day/$500 mo Y
7 ($36.82 day/$1,120 mo) :(.4
$39.45 . ; Level 4 518.08 day/$550 mo Level 4 $14.79/5450 mo
+$.66 Respite Care ''. Ongoing crisis intervention as needed, Regularly scheduled weekly
4 multiple sessions,can include
TRCCF ,L,;:,,, which includes high level of case Y more
Drop Down � r management and CPA involvement with " than 1person,i.e.family
c ($40.11 day/S1220 mo) g , ' therapy,
Y child and provider and 2-3 face-to-face 0 for 9-12 hours/monthly. j.
contacts r week minimum. €
a' V,Assess/ 3,,.
Emergency $30.25 day/$920 mo -: $13.15 day/5400 mo
Level (Includes Respite) ,:`i
Rate
Admin.Overhead Rate:
$6.91 day/$210.00 month
7
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
f,1La OF THE WELD COUNTY
DEPARTMENT OF HUMAN
SERVICES
Ito
By: iii /_ a /�;:i B i� C / i i 1r i'c . 4
Depu lerk to the Board�� , Chair ignature
°EP 2 6 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Lutheran Family Services
OF HUMAN SERVICES of Colorado,3f 5 5. S.)
2032 verve , Suite 200 ^ /
Fort Collins,C teed A .
By: By:
Dir c r
(oi/-0753;
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Smith Agency Inc. and Weld County
Department of Human Services for the period from
July 1, 2011 through June 30, 2012.
The following provisions, made this I day of 7L.) l�'7 , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of t!fe Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the CPA identified as Provider ID#44882. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. County and Contractor agree that for Children's Habilitation Residential Program
(CHRP) waiver eligible children, the County agrees to pay the federal SSI rate to
Contractor and all other service costs will be billable under the CHRP program.
4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
5. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
6. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
7. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
019(9//-A5-32I Weld County SS-23A Addendum
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
9. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Service Utilization Unit. Contractor
shall be notified by County staff of the date and time of the review.
10. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County
Department of Social Services to shorten the duration of placement.
11. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days
and dental examinations completed within 8 weeks of the child being placed with
Contractor. All documentation of these examinations shall be forward to the County.
12. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized
Educational Plan (IEP) for youth designated as a Special Education Student every 3 years
and coordinate reviews every year. If the IEP is due while the child is in placement, the
Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to
the County.
13. Add Paragraph 18 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
14. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
15. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
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.
2 Weld County SS-23A Addendum
16. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
18. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term"litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
19. Add Section VII - EXHIBITS:
3 Weld County SS-23A Addendum
• (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
IDENTIFYING INFORMATION
('HILD'S NAME STATE ID# rAEX F [TRAILS CASE ID jDOB
WORKER COMPLETING ASSESSMENT 1111 'DATE OF ASSESSMENT
AGENCY NAME rROYIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week ❑I)One round trip a week ❑1'/:)2 round trips a week
02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week
❑3%:)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required DI)Once a month ❑1'/i)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
03%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑I)Less than a '/,hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 %) I'/z-2 hours per day 03)21/4-3 hours per day
❑3''/) More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed DI) Less than 5 hours per week ❑1'/)5 to 7 hours per week
02)8 to 10 hours per week 02%) I 1 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond 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 ❑l'/)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%a)21 or more hours per week
A I. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
DI)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'%) Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention.
02%) Face-to-face contact three times per month with child and occasional crisis intervention.
03) Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T I. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑l)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
(Exhibit B)
" WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that as•I to this child.
.:Bit7,- ?fir ', .g 4 . ^;:A' krei "` , s=;.t.i
8 •i re �
t:,. '.., wts rw FWea. a4.ys. • r o- • .. • 1.-.:1'i:-Ci:',= : 1, r,it, :•a.‘ it.t
Aggression/Cruelty to
Animals ❑ O O O 0
0
0
Verbal or Physical
Threatening O ❑ ❑ ❑ ❑ ❑ ❑
Destructive of
Property/Fire Setting O O O O O O O
Stealing
❑ O O O O O O
Self-injurious Behavior
❑ O O O O O O
Substance Abuse
❑ O O O O O O
Presence of Psychiatric
Symptoms/Conditions ❑ O O O O O O
Enuresis/Encopresis
O O O O O O O
Runaway
❑ O O O O O O
Sexual Offenses
O O O O O O O
5 Weld County SS-23A Addendum
•
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensit of conditions which create the need for services that a..l to this child.
+t 5 ` .. 1 a j "$. F Y ry h 5 i Y ?
S 4' ' .x '5°+link x • 'h § k `i. 4,'�t f 'f.'
�
a{m`�-- �� a n`'�° °'n � 1--.1. '� S� #'��i 4 ,�t"f ,r°;�`,� < �*' ` a -� �'
a 4i6:i . x f.... ••,,,,,. s.x P ;fig: . y � .i, p s r k v #' *s .'s
b'Ii - 1 f : ���[( i i,ti ' 4 h -.asa • 4 ( d L'§f3 § "y, ffteF
''*^d k $ 1. 1 £ `t �..•
w .es 'vrh t" u� ° u � �'°+v�a'�ta °x:��s�aw �
wt" li,n r +t*,cSas xs+ s *<fr' �rct vft5 �, : ai ,Ts,� €a, a � �}
aa.as +",., .v t* z . #,�F � a.r .,�
.. ,..:,a��. t<w. ':",�'a'�n•..o...,. s.s... .<. .....t m.;. .t, . ,.,xy;'h. r"hla.. ...,.
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ 0 0 ❑ 0 0 0
Delinquent Behavior
❑ 0 0 0 0 0 0
Depressive-like Behavior
❑ 0 0 0 0 0 0
Medical Needs
(If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
❑ 0 0 0 0 0 0
Eating Problems
❑ 0 0 0 0 0 0
Boundary Issues
❑ 0 0 0 0 0 0
Requires Night Care
❑ 0 0 0 0 0 0
Education
❑ 0 0 0 0 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 ❑ PA ❑ 2 ❑ 2'A ❑ 3 ❑ 31/4
6 Weld County SS-23A Addendum
•
(Exhibit C)
WELD COUNTY DEPARTMENT OF RUMAN SERVICES
NEEDS RASED CARE
RATE TABLE
a
5'iLy - t E § h %L'4,ririv`. . .... r ', , k P t o-i ate'
. .n.vad ¢vh .l. -... . .... 4e
"; Age 0-10..$16.32 < � Y
($496) ';;;•‘; Basic Maint $4.93 day/$150mo Level 0 $0
Coun Age 11-14...$18.05 k.;S Therapy not needed or provided
Basie ($549) 5}2.4 No crisis intervention,Minimal CPA p by Level 0...$0
Maint. iii
• Age 15-21...$19.27 ',1' } (None)
($586) ,,,.,:d involvement,one face-to-face visit '§1 another source,i.e.mental health.
+$.66 Respite Care )rb 7e.
($20) Y with child per month. 9.
WI
$19.73 Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
tb +$.66 Respite Care Minimal crisis intervention as needed, ttS, Regularly scheduled therapy,
1 .::',I': one face-to-face visit per month with Level 1 ...$2.99
:SIIII ($20.39 day/$620 mo) r, child, ti,M
' up to 4 hours/month.
Alir 2-3 contacts per month n
$23.01 *
r.
1 1/2 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo "')b --
($23.67 day/$720 mo) rt. •
i I $26.30 Level 2 $11.51 day/$350 mo y Level 2 $9.86/$300 mo 111
i
2 " +$.66 Respite Care Occasional crisis intervention as needed, kiii Weekly scheduled therapy,
4.4 Rci �+ Level 2..$ 7
($26.96 day/$820 mo) two face-to-face visits with child,50 t:,t; 5-8 hours a month with 4 hours of
•
". 2-3 contacts per month ,.,, group therapy.
-
$29.59IDA
2 1/2 ' +$.66 Respite Care ( Level 2 1/2 $13.15 day/$400 mo
i4t;Wit ($30.25 day/$920 mo) a
$32.88 a Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo
a1WI
+$.66 Respite Care .;•.;,;;;! Ongoing crisis intervention as needed, _ s Regularly scheduled weekly
3 multiple sessions,can include Level 3..$6.02
weekly face-to-face visits with child more
($33.54day/$1020 mo) and intensive coordination of than 1 person, i.e.family therapy,bkSI4TN&. `w multiple services. � for 9-12 hours/monthly.
RIgi $36.16iziil
3 1/2 WTI +$,66 Respite Care .'i R Level 3 1/2 $16.44 day/$500 mo
If ($36.82 day/$1,120 mo)
,
$39.45 Level 4 $18.08 day/$550 mo .49 Level 4 $14.79/$450 mo
Ar
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
4 multiple sessions,can include siii
TRCCF s; which includes high level of case more Level 4....Neg.
Drop °
Down �,'�. ($40.11 day/$1220 mo) management and CPA involvement with t." than 1 person, i.e.family therapy,
child and provider and 2-3 face-to-face for 9-12 hours/monthly.
s+�'�• contacts .er week minimum. Lai
Zitl
Assess/ '
Emergency a $30.25 day/$920 mo s1 $13.15 day/$400 mo s" T'-1`;
Level ' (Includes Respite) s fIr. r
Rate .1-,,,: +ia i':S-
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF
•�� SOCIAL SERVICES, ON BEHALF
E L OF THE WELD COUNTY
® DEPARTMENT OF HUMAN
SERVICES
361 t 144
By: id � 1►�! ./.�►:L�� '�Ii `�� B�� W(GC Lc Lc, c .,
Depu Clerk to the Bo S,�J ( ' V Al Cha' Signature/
Approval as to Substance: CONTRACTOR �EP 2 2011
WELD COUNTY DEPARTMENT Smith Agency Inc.
OF HUMAN SERVICES 14394 E. Evans Ave
Aurora, CO 80014-1408
By: By: � .�
D ector
°,9O//-07,5S9
8 Weld County SS-23A Addendum
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