HomeMy WebLinkAbout20112196 MEMORANDUM
1 8 6 1 - 2 0 1 1 DATE: August 4, 2011
TO: Barbara Kirkmeyer, Chair, Board of Co ty Com is 'oners
C2
• FROM: Judy A. Griego, Director, Human rv. esDep me
WELD__000NTY
II RE: Individual Provider Contracts for Purpose of Foster Care
u Services and Foster Care Facility Agreements and the Weld
County Addendums to the Agreements between the Weld
County Department of Human Services and Various
Providers for Consent Agenda
Enclosed for Board approval are Individual Provider Contracts for Purpose of Foster Care
Services and Foster Care Facility Agreements and the Weld County Addendums to the
Agreements between the Department and Various Providers. These Agreements can be
placed on the Consent Agenda.
The major provisions for these Agreements are as follows:
No. Provider/Term Facility Type/Location
1 Almond, Earl and Cindy Foster Home
July 1, 2011 —June 30, 2012 Johnstown, Colorado
2 Baker, Elissa Foster Home
July 1, 2011 —June 30, 2012 Windsor, Colorado
3 Beaman, Diane and Chad Foster Home
July 1, 2011 —June 30, 2012 Greeley, Colorado
4 Carter, Jeremy and Susan Foster Home
July 1, 2011 —June 30, 2012 Windsor, Colorado
5 Castillo, Arturo and Elsa Foster Home
July 1, 2011 —June 30, 2012 Fort Lupton, Colorado
6 Corliss, Wade and Loni Foster Home
July 1, 2011 —June 30, 2012 Greeley, Colorado
7 Erbacher, Dan and Hallie Foster Home
July 1, 2011 —June 30, 2012 Greeley, Colorado
8 Fisher, Matthew and Claire Foster Home
July 1, 2011 —June 30, 2012 Greeley, Colorado
9 Foster, Denise Foster Home
July 1, 2011 —June 30, 2012 Firestone, Colorado
10 Fritz,Nancy Foster Home
July 1, 2011 —June 30, 2012 Evans, Colorado
11 Froggatte, Samuel and Rachelle Foster Home
July 1, 2011 —June 30, 2012 Greeley, Colorado
CI- NS
/C � ,1 � 'II 2011-2196
12 Gariepy, Susan J. Foster Home
July 1, 2011 —June 30, 2012 Greeley, Colorado
13 Gerardy, Jerry and Priscilla Foster Home
July 1, 2011 —June 30, 2012 Evans, Colorado
14 Gomez, Oswald and Christina Foster Home
July 1, 2011 — June 30, 2012 Fort Collins, Colorado
15 Hays, Stephen Dale and Chantel Foster Home
July 1, 2011 —June 30, 2012 Fort Lupton, Colorado
16 Heimer, Sara Foster Home
July 1, 2011 —June 30, 2012 Greeley, Colorado
17 Hernandez, Paul and Catherine Foster Home
July 1, 2011 —June 30, 2012 Loveland, Colorado
18 Hernandez, Roberto and Margarita Foster Home
July 1, 2011 —June 30, 2012 Fort Lupton, Colorado
19 Hess, John and Betty Foster Home
July 1, 2011 —June 30, 2012 Greeley, Colorado
If you have questions, please give me a call at extension 6510.
l:WS-/A(KIU-IU/99)
4 INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, 7//11 by and between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called"County Department" and,
Almond, Earl and Cindy, Provider ID#61603, 1000 Country Acres Dr., Johnstown, CO
80531, hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
LWS-/A (KIU-10/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
LWS-/A(KW-IV/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
+tom
ATTEST: Weld County Clerk to t i't:rW,IL WELD COUNTY BOARD OF SOCIAL
�N `�� SERVICES, ON BEHALF OF THE WELD
�0 t COUNTY DEPARTMENT OF HUMAN
L s� e' SERVICES
y .= .
Depu,r erk to the Boat' . (11 •yam Chair Sign ure
AUG 1 0 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Almond, Earl and Cindy
OF HUMAN SERVICES 1000 Country Acres Dr.
Johnstown,
.(//n,, CO 80531 rn
By: By: 'L4 a
Irecto By:
3
(90//-07/5
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Almond, Earl and Cindy
and the
Weld County Department of Human Services
for the period from July 1,2011 through June 30,2012.
The following provisions, made this / day of J 41 , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the/Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#61603. These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System(FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
• PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
• C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week 01%)2 round trips a week
02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week
03%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month O1%)Two times month
02)Three times a month ❑2%n)Once a week 03)Two times a week
03%)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1)Less than a ''/3 hour per day 01%) 1/2 hour a day
02) 1 hour a day 02 %n) 1''/-2 hours per day 03)2'/-3 hours per day
03%)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03) Face-to-face contact weekly with child and occasional crisis intervention.
❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
5 Weld County Addendum to the CWS-7/
(Example only do not complete) (Exhibit B)
WELD COUNTY DIIS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensi of conditions which create the need for services that as el to this child.
, . - to �..
Y2. . ..R,YA q�l {qt at E4 �qu, f
e i�
tit'�eEF 43 S \ S
fl. • .
�� v •� r pr sw+ yld� 4 t t j a �' '�h §, ,,...4:
. rr ? m- 3drxs .r.a,: .. *.x�,,.sv C..r ;u�-...._..:,
Aggression/Cruelty to
Animals ❑ O ❑ ❑ ❑ ❑ ❑
Verbal or Physical
Threatening ❑ O O ❑ O O O
Destructive of
Property/Fire Setting ❑ O O O O O O
Stealing
❑ ❑ ❑ ❑ 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 ❑ ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ O ❑ O O
6 Weld County Addendum to the CWS-7/.
(Example only do not complete) (Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that a 8 r 1 to this child.
tt ..
�wys ,r ;t y. r � �'
i4. $ t 1 .mm i Pu5 •x
Inappropriate Sexual
Behavior O O O O O O O
Disruptive Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ O ❑
please complete the Medically
fragile NBC)
Emancipation
❑ O O O O O O
Eating Problems
❑ O O O O O O
Boundary Issues
❑ ❑ ❑ ❑ ❑ ❑ ❑
Requires Night Care
❑ O O O O O O
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
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 El ❑ 1'h ❑ 2 ❑ 272 ❑ 3 ❑ 3'h
7 Weld County Addendum to the CWS-71
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
„'4
Age 0-10...$16.32/day ($496/month)
.
County Basic .'! Age 11-14...$18.05/day ($549/month)
Maintenance
Rate Age 15-21...$19.27/day ($586/month)
i
+Respite Care$.66/day ($20/month)
$19.73
+$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
u,?�
a.
$23.01
1 1l2n +$,66 RespRe Care
/$72 Total Rate=($23 day0 month)
.67
$26.30
2 E +$66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
t.; Total Rate=($36.82 day/$1,120 month)
iw5
4 Wn $39.45
TRCCF Drop Down :i➢s§', +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Asses--Ratemergency y $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the h yard WELD COUNTY BOARD OF SOCIAL
Slide
d SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
1/41
61
By. ' .�/ /..( � �.e % �/J�i? B �� 1L aj{71_1 /z
Deputy //erk to the B�tsl (�� f� Chair Sig ature
AUG 10 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Almond, Earl and Cindy
OF HUMAN SERVICES 1000 Country Acres Dr.
Johnstown, CO 80531
C (//
By: By: r
D hector
v By: a,- cgc// 19.4
9 Weld County Addendum to the CWS-7A
I.WJ-/A(KIU-IU/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, (( by and between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Baker, Elissa, Provider ID# 1552821, 1224 Westwood Dr, Windsor, CO 80550, hereinafter
called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
a'bi/L&J9�
LWJ-/A(KIU-IU/99)
•11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
LWJ-/AtKIU-IU/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the B.-C� WELD COUNTY BOARD OF SOCIAL
I. /`% SERVICES, ON BEHALF OF THE WELD
i I COUNTY DEPARTMENT OF HUMAN
. .ERVICES
•
By %���/ ./ �: ���! �i��..� � I-14, A-
Depu t'erk to the Boa t /�j I Chair Signa rk G 1 O 2011
♦ AU
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Baker, Elissa
OF HUMAN SERVICES 1224 Westwood Dr
Windsor, CO 80550
By:
JBy:
).1A
iirector
JJ ttt By
3
&.?-"5//-- /9E
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Baker, Elissa
and the
Weld County Department of Human Services
for the period from July 1,2011 through June 30, 2012.
The following provisions, made this 6 day of�G 74 2011, are added to the referenced
Agreement. Except as modified hereby, all terms ii the ,�4cc¢¢�T))eement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1552821. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
67e)//-2/yG
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five(5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A S-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑�B is Maint.)Less than one round trip a week ❑1)One round trip a week ❑I'/:)2 round trips a week
,�,
L`�l)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week
❑3%:)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
asic Maint.)No participation required ❑1)Once a month ❑1%)Two times month
02)Three times a month ❑2%:)Once a week 03)Two times a week
❑3%)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
Basic Maint.)No educational requirements ❑1)Less than a '/,hour per day 01%)1/2 hour a day
02) 1 hour a day 02 %) 1'/,-2 hours per day 03)2'/:-3 hours per day
❑3''/)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
O Basic Maint.)No special involvement needed g1)Less than 5 hours per week ❑1''/)5 to 7 hours per week
02)8 to 10 hours per week ❑2%) I I to 14 hours per week
❑3)Constant basis during awake hours ❑3/)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond aee appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
asic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week
02) 8 to 10 hours per week 02%) I I to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week ' n e{-s r
Comments: WA. ( Ll�®�1 Cµ� i It V`X 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.)
Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%)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?
V0)Not needed or provided by another source(i.e. Medicaid) ❑I)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child.
1
rips E4' e 1
4 r. .
J y asr. r d i .p p �
"..... . - 4 .. .. ...�C'�.+Yd ]i3h ^...„eviS ik 4a�#45r'+yr.
Aggression/Cruelty to
Animals 0 V ❑ ❑ ❑ ❑ ❑
Verbal or Physical /
Threatening uE/ ❑ 0 0 0 0 0
Destructive of
Property/Fire Setting ,c3/ 0 0 0 0 0 0
Stealing /EfeSelf-injurious Behavior /
�r ❑ 0 0 0 0 0
Substance Abuse /[ElPresence of Psychiatric
Symptoms/Conditions �f r ✓ 0
0 0 0 0
Enuresis/Encopresis
ID o 0 0 0 0 0
Runaway /
cl ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
0 0 0 0 0 0
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that as.I to this child.
e.. 4 r . ''[.;1:::::',:':,.::: i ;
d .
` � G₹ems�y'
''*^ut•' r f 9 fl � t w'.�..�`...s„usx
it
Inappropriate Sexual
Behavior - O O O ❑ O O
Disruptive Behavior
iLit O O O O O O
Delinquent Behavior
❑ ❑ ❑ ❑ ❑ ❑
Depressive-like Behavior
O O O ❑ O O
Medical Needs G� r t- tC1 C-
(Ifcondition is rated"severe', ❑ jar O O O O O
please complete the Medically
fragile NBC)
Emancipation
O O O O O O
Eating Problems LA otAiu`-lam
Ad---Mnsslhvvi it
Boundary Issues
❑ O O O O O O
Up t
Requires Night Care 3 - x SCO
Ikt
U
Education
V5 ❑ ❑ ❑ ❑ ❑ ❑
Involvement with Child's
Family O O O O O ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1''A ❑ 2 ❑ 2V ❑ 3 ❑ 3%
7
Weld County Addendum to the CWS-7A
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
w �
Age 0-10...$16.32/day ($496/month)
County Basic iF Age 11-14...$18.05/day ($549/month)
Maintenance aw
Rate ,F Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
A≥re $23.01
1 112 ;i}q +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
zS�
$26.30
2 u 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 112 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
r ' 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
r
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
561 I l „ � S�
II ♦�4nP• q � I �
By: i�a / ? . �? i. !� A B 1 : 6)¢ }bud Y'
Deputy perk to the Chair Si ature
� 5'� AUG 10 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Baker, Elissa
OF HUMAN SERVICES 1224 Westwood Dr
Windsor, CO 80550
By: B :
irector
By.
??c//- /9H
9 Weld County Addendum to the CWS-7A
LWS-/A(KIU-IU/99) l -
INDIVIDUAL PROVIDER CONTRACT I a
FOR PURPOSE OF FOSTER CARE SERVICES /�
AND Les 1 �� Cbbi
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, / r2-2 by and ben
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of 2S
the Weld County Department of Human Services, hereinafter called"County Department" and,
Beaman, Diane and Chad, Provider ID# 1560953, 2808 22nd St Rd, Greeley, CO 80634, Q
hereinafter called "Provider." n-
u'
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
aG//-a/2
L W S-/A tK I U-I U/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child -
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placment and
may be changed upon mutual agreement of the provider and the County Departmef4% ,
recorded in the Family Services Plan. th
13. To report promptly to the Department: 9 0
a. Any unplanned absence of the child from provider's care. 3
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
LW -/A tK1 U-I V/YY)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks e•of pl to remove a child from tht:. cility. The two-week notice
may be waived by mut .. o mmeektle't'ewov71 ofyaid-child for placement
elsewhere, or without such waiver-in-the..event drari einergency?An emergency is defined as any
situation in which a provider's inability to pfovide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made iereof
on a case by case basis. _
c-
14. To provide notice of hearings. S
N
Additional Agreement regarding a Particular Child: `j'
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement. A
ATTEST: Weld County Clerk to the =.* �IL ,/�,P%WELD COUNTY BOARD OF SOCIAL
/� ,V N ` ' `ERVICES, ON BEHALF OF THE WELD
/� • r '•` ��•UNTY DEPARTMENT OF HUMAN
ygt RVICES
tact 1[[�rw s
•
By: �y 4JJyJ z , 5
Deputy lerk to the Board - Chair Sig ature
AUG 10 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Beaman, Diane and Chad
OF HUMAN SERVICES 2808 22nd t Rd
Greeley, C 80634
By: _ B .
(\kr-,
r
J ` By:
3
C// -O799
iiiiitiov;
, s\WELD COUNT DE D
To that certain Individual Provider Contract for Purpose of Foster Carec2;.
Services and Foster Care Facility Agreement(the "Agreement") between ,/./
Beaman, Diane and Chad ` 1
and the
Weld County Department of Human Services 1
for the period from July 1, 2011 through June 30, 2012. 90)
The following provisions, made thisa2 day of s'\111_,2011,are added to the referenced
Agreement. Except as modified hereby, all terms of the AgQement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1560953. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
o7C//- c7/2
l Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the Ay.a disci gr ,e.
y
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Vis' Lion; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
asic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1'/n)2 round trips a week
02)3-4 round trips a week. ❑2%)5 round trips a week 03)6 round trips a week
❑3%)7 round trips or more
Comments: flb1\_q
P 2. How of en is the foster care provider required to participate in child's therapy or counseling sessions?
Basic Maint.)No participation required ❑1)Once a month O1%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
03%)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
asic Maint.)No educational requirements ❑1)Less than a'/:hour per day 01%) 1/2 hour a day
2) 1 hour a day 02 %) 1'/:-2 hours per day 03)2'/2-3 hours per day
❑3'/:) More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or 'vities 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 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding.
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'/) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more h rs per week
Comments: it I\S.—
•
A 1. How en is CPA/County case management required?(Does not include therapy)
asic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑l)Face-to-face contact one timeper month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%)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 ten are therapy services needed to address child's individual needs per NBC assessment?
0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the C W S-7F
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensi of conditions which create the need for services that al i I to this child.
r¢
rk
.. a @ 0. ..i... .':u . . ';.. .
Aggression/Cruelty to
Animals 0 0 0 0 0 0 0
Verbal or Physical
Threatening 0 ❑ ❑ ❑ ❑ ❑ ❑
Destructive of
Property/Fire Setting 0 0 0 0 0 0 0
Stealing
❑ 0 0 0 0 0 0
Self-injurious Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Substance Abuse
❑ 0 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 0 0 0 0
Enuresis/Encopresis
❑ 0 0 0 0 0 0
Runaway
❑ 0 0 0 0 0 0
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that a..l to this child
hkia<• i•.
..... •
Inappropriate Sexual
Behavior O O O O O O O
Disruptive Behavior
❑ ❑ ❑ ❑ 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", O O O O O O O
please complete the Medically
fragile NBC)
Emancipation
❑ O O O O O O
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑ ❑ ❑ ❑
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 ❑ 172 ❑ 2 ❑ 2% ❑ 3 ❑ 3'/
7 Weld County Addendum to the CWS-7A
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE•� v
t
i � —3
,•
S t t h Y
gt SE 11 •
k tp4Hy'y
s .. t o-a 3 x}i'+,t r a1'� .'
•
Age 0-10...$16.32/day ($496/month)
County Basic § Age 11-14...$18.05/day ($549/month)
Maintenance o-,a
Rate Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
1i
;.. $19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 112 +166 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$,66 Respite Care
Total Rate=($30.25 day/$920 month)
y
$32.88
3 +$,66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down *$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate g.
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to th- : ..rd WELD COUNTY BOARD OF SOCIAL
4._slide SERVIMS;17N BEHAL'P OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
I `�nlb
x .61
By: ' �1% /. , " Ir�/ii:'ll ����'B ;L ,[, /cam
Deputy t erk to the B y (r V ' .i Chair Sig ature
AUG 1 0 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Beaman, Diane and Chad
OF HUMAN SERVICES 2808 22nd St Rd
Greeley, CO 80634
By: B •
Di ector
By:
9 Weld County Addendum to the CWS-7A
UN/S-/A(KM-IIPYY)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMUIL 1 q le S]
1. THIS CONTRACT AND AGREEMENT, made this date, ----Oil by and between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Carter,Jeremy and Susan, Provider ID# 1556173, 1204 Tanglewood,Windsor, CO 80550,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
dC/%-677/9
I:W N-/A tKIU-IU/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
L W J-/A tK I U-I U/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk tot f J 3s WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
# • COUNTY DEPARTMENT OF HUMAN
SERVICES
BY s//' / I '�%?�, ..�A'� By:
Deputyrlerk to the Bo Chair Sign ure
AUG 1 0 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Carter, Jeremy and Susan
OF HUMAN SERVICES 1204 Tanglewood
Windsor, CO 80550
By: By:- -
irector
By: `1. ')il
3
v7Oi/- C/9�
I
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract foialiirdijEe titFoe,Cnare
Services and Foster Care Facility Agreement(the "Agreement' 'tlet eel
Carter,Jeremy and Susan
and the
Weld County Department of Human Services
for the period from July 1, 2011 through June 30,2012.
The following provisions, made this l t, day of u._) , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1556173. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment. �7
,D C//-0V 91
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 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 01%)2 round trips a week
02)3-4 round trips a week. ❑2''/)5 round trips a week 03)6 round trips a week
03%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month ❑1'/:)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
03%)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements 01)Less than a '/:hour per day 01%) 1/2 hour a day
02) 1 hour a day 02 %) 1'/:-2 hours per day 03)21/2-3 hours per day
03%)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week ❑I'/)5 to 7 hours per week
02) 8 to 10 hours per week ❑2''/) 11 to 14 hours per week
0 3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond ate 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
02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3'/)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child.
srt:FITT!Agni:271-7.“:';a
'Ctd � e t' x J'4
Aggression/Cruelty to
Animals ❑ O ❑ ❑ ❑ ❑ ❑
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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ O O O O O
Presence of Psychiatric
Symptoms/Conditions ❑ O ❑ O O O O
Enuresis/Encopresis
❑ ❑ O ❑ O O O
Runaway
❑ ❑ O O O O O
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
' WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that a'I I to this child
b
4 '
v ffy
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 O O
Medical Needs
(If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ ❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ ❑ O ❑
Boundary Issues
❑ O O O O O O
Requires Night Care
❑ ❑ ❑ ❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
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 Ell ❑ 11/2 ❑ 2 ❑ 2'% ❑ 3 ❑ 3'/2
7 Weld County Addendum to the CWS-7A
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
r%' A.e 0-10...$16.32/da $496/month
County Basic •mcsl A.e 11-14...$18.05/da $549/month
Maintenance ?_
Rate A.e 15-21...$19.27/da $586/month
+Resale Care$.66/da $20/month
$19.73
1 ^''h +$.66 Respite Care
" Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 " +$.66 Respite Care
.1 Total Rate=($23.67 day/$720 month)
7@3�
w.:
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
Ivo
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4i�e"'a
4 ;`: $39.45
TRCCF Drop Down v +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency i
Rate $30.25 day/$920 month(Includes Respite)
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the B.ar. WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
Las%COUNTY DEPARTMENT OF HUMAN
• r , I ERVICES
1x614441*
Deputy erk to the Boa?�� ( \ Chair S gnature
AUG i 0 2611
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Carter, Jeremy and Susan
OF HUMAN SERVICES 1204 Tanglewood
Windsor, CO 80550
By: By:
y—,
Di ctor
By: _ ' ( ,O Til
poi/- a JA
9 Weld County Addendum to the CWS-7A
CWS-/A(KIV-IV/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, 774/ by and between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Castillo, Arturo and Elsa, Provider ID# 1592544, 905 Greenwood Ct., Fort Lupton, CO
80621, hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1. WS-/A(KIU-IU/YY)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
• placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
LWJ-/A(KIU-IU/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
• 5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the s � `'. 1. /�'% WELD COUNTY BOARD OF SOCIAL
If r-c ERVICES, ON BEHALF OF THE WELD
DEPARTMENT OF HUMAN
t!6 *.UNTYRVICES
By: ,„„y :/- ��.� MaXei N \ JB : 1L
Deput`er to the Board �► " lose Chair Signa re
Approval as to Substance: PROVIDER AUG 1 2011
WELD COUNTY DEPARTMENT Castillo, Arturo and Elsa
OF HUMAN SERVICES 905 Greenwood Ct.
Fort Lupton, CO 80621
By: � C e C cU
D ector
By: /(
i�� ,( � (Y-8
3
aO//- a
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Castillo,Arturo and Elsa
and the
Weld County Department of Human Services
for the period from July 1, 2011 through June 30,2012.
The following provisions, made this / day of J. , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of th Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1592544. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
,5P cii-a12,
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 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. 02%)5 round trips a week 03)6 round trips a week
❑3%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month 01%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3'/n)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
O Basic Maint.)No educational requirements 01)Less than a ''/z hour per day 01%)1/2 hour a day
❑2) I hour a day 02 %) 1'h-2 hours per day 03)2'/z-3 hours per day
03%)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) I I to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑l)3 to 4 hours per week 01%)5 to 7 hours per week
02)8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%) Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3'/)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (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 s el to this child.
w
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
Presence of Psychiatric
Symptoms/Conditions ❑ O O O O O O
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ O O O O O O
Sexual Offenses
❑ O O O O O O
6 Weld County Addendum to the CWS-7A
• (Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that al II to this child.
4-ci ti i P
l.341133i4i:y -:54;k: F z
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
Eating Problems
❑ O O O O O ❑
Boundary Issues
❑ O O O O O O
Requires Night Care
❑ ❑ O O O O ❑
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
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 ❑1 ❑ 11/4 ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'/
7 Weld County Addendum to the CWS-7A
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
s „ s 3 M a y" mxt
S `'•cx=`r� i s
�f� R ` vCUA'iM4w`a'
Aye 0-10...$16.32/da $496/month
County Basic } Ase 11-14...$18.05/da $549/month
Maintenance r,
Rate A'e 15-21...$19.27/da $586/month
+Res.ite Care$.66/da $20/month
,444
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 112 ti ', +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 #_ _ +$.66 Respite Care
° Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
reitifit
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
• IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to t. • ., d WELD COUNTY BOARD OF SOCIAL
Vasa a% SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By: �_s�iy �, � J,ti�Ir= !S "4 11k i2 / lA,
Deputy erk to the : ` � Chair Si ature
AUG 10 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Castillo, Arturo and Elsa
OF HUMAN SERVICES 905 Greenwood Ct.
Fort Lupton, CO 80621
By: By: ! "'/zio i r c
hector
By: �� (-1 t
o?D//
9 Weld County Addendum to the CWS-7A
LWJ-/A(KIU-1U/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS the Board Nof Weld CouTRACT Dnty Commissioners, sitting as the Board o b t8(5erGlces AGREEMENT, made this date, pH s,, on behyiepi alf en
al of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Corliss, Wade and Loni, Provider ID# 1547483, 26649 CR 60 1/2, Greeley, CO 80631,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
GWJ-/A(KIU-IU/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
LWS-/A(KIU-11J/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Cle to the Bo „p��` WELD COUNTY BOARD OF SOCIAL
\La SERVICES, ON BEHALF OF THE WELD
� Y�, • �1J COUNTY DEPARTMENT OF HUMAN
ERVICES
� 4O'
186 ( t��S
By: �.d/r,G i. �!_!14.'I�'!�r� 5!� y 1,2 rU� ,1}}-
Deputy,%erk to the Boa i ��
�j��p Chair Signa ure
Approval as to Substance: '�bV PROVIDER AUG 1 0 2011
WELD COUNTY DEPARTMENT Corliss, Wade and Loni
OF HUMAN SERVICES 26649 CR 60 1/2
Greeley, CO 80631
By ( By:
irec or
3
aC//- 07/ 24
s �
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement")) between -
Corliss, Wade and Loni 2QI JUL -8 A ID IS
and the
Weld County Department of Human Services
for the period from July 1, 2011 through June 30,2012.
The following provisions, made this / day of JA I , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1547483. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
c)7d/A /2
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
• ' PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
•
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY OHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week DI',')2 round trips a week
❑2)3-4 round trips a week. ❑2'/i)5 round trips a week O3)6 round trips a week
O3%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required DI)Once a month ❑1'/:)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
❑3%:)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements DI)Less than a'/hour per day ❑1%) 'h hour a day
O2) 1 hour a day O2 '/i) 1'/z-2 hours per day O3)2'/2-3 hours per day
❑3%) More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed DI)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 O3%)Nighttime hours
Comments:
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 ❑I'/)5 to 7 hours per week
O2) 8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week
O3%)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
DI) Face-to-face contact one time per month with child and minimal crisis intervention.
01%) Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑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
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (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
:;t7),,:;',..24:,:,: t TJi E};:.:H•
k t P ,4.;:i.,„:,,,,,,,1.1
L
'e^.s.x,.s'+.:44.-}`^.`,t...,i.x. ' ,g,.. ..' . :F. :.`c 3`x .�uw'0crvdN '"'i .'
xt ePYts:k sX5%�'..§ :4.xi'�"#.�$:°% ...
Aggression/Cruelty to
Animals ❑ 0 ❑ ❑ ❑ ❑ ❑
Verbal or Physical
Threatening ❑ 0 0 ❑ 0 0 ❑
Destructive of
Property/Fire Setting 0 0 0 0 0 0 0
Stealing
❑ 0 0 0 0 0 0
Self-injurious Behavior
❑ 0 0 0 0 0 0
Substance Abuse
❑ 0 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 ❑ ❑ 0 ❑ ❑
Enuresis/Encopresis
❑ 0 0 0 0 0 0
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (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..I to this child.
7
F �
a
T1-::;:: �+.'*.6:� ...=e,a., . . .... . . . .. ,...t.x+n rota . . . �... . tyt��:s;:ka a .ez':4h',,Ii‘4
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ 0 0 0 0 0 0
Delinquent Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe", ❑ 0 0 0 0 0 0
please complete the Medically
fragile NBC)
Emancipation
❑ 0 0 0 0 0 0
Eating Problems
❑ 0 0 0 0 0 0
Boundary Issues
❑ ❑ ❑ ❑ ❑ 0 0
Requires Night Care
❑ ❑ 0 0 0 0 0
Education
❑ 0 0 0 0 0 0
Involvement with Child's
Family 0 0 0 0 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) O 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'A ❑ 3 ❑ 3'/
7 Weld County Addendum to the CWS-7A S-7A
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
fr m F' • twriq• " � s'= 7gFK ' .»x
•
yam
�
*r ,
A•e 0-10...$16.32/da $496/month
County Basic ¢?u°l A•e 11-14...$18.05/da $549/month
Maintenance
Rate Ate 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 kos +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
ilk Total Rate=($33.54day/$1020 month)
$36.16
3 1/2
+$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
EON
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A S-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
S V I 4` is
La COUNTY SD,
ETA
RTMENT OF HUMAN
D
fi
-
,� -,SERVICES
• 1%61 'Silt
Ci;iorBy.
ii / By. Jcitl
' -
Deputy ' lerk to the B WC' I Chair i ature
AUG 1 0 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Corliss, Wade and Loni
OF HUMAN SERVICES 26649 CR 60 1/2
Greeley, CO 80631
By: By:
D rector By t,_/J C
ae/%d/9<
9 Weld County Addendum to the CWS-7A
e
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster 1�Care fin
Services and Foster Care Facility Agreement (the "Agreement") between 9 Sy
Erbacher, Dan and Hallie
and the
Weld County Department of Human Services
for the period from July 1, 2011 through June 30, 2012.
The following provisions, made this /1f day of Lk , 2011, are added to the referenced
Agreement. Except as modified hereby, all term of th6Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1546381. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator,prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
oroi/- ai9�
1 Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week ❑1)One round trip a week 01%)2 round trips a week
02)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week
03%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
0 Basic Maint.)No participation required 01)Once a month ❑l%)Two times month
02)Three times a month ❑2%:)Once a week 03)Two times a week
❑3'/)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1)Less than a%hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 %) I''/-2 hours per day 03)2'%-3 hours per day
❑3''/)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1'/:)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3/)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 011/2)5 to 7 hours per week
02)8 to 10 hours per week ❑2'/i) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3/)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
Du 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.
❑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
5 Weld County Addendum to the CWS-7P
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behaviorhntensit of condtttons which create the need for services that a..1 to this child.
k,Sr 2++# {� �9t 's .aii - q ��}` ' 1 a 3
M
. r' ,- .au -�a .c e�'' a `u
y� i [
F v' wF't' � x � � i f {� fii 4k �.' � cu {���.� ui'�t E
„ 'a+e';+-a�1?. ' xis � Ufa 4� :r.z:.6FwE:.fi .
Aggression/Cruelty to
Animals 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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ O O O O O O
Sexual Offenses
❑ O O O O O O
6 Weld County Addendum to the CWS-7A
(Exhibit B)(Example only do not complete)
' 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.
t ¢
`` a : s s vs a v�4'v;L`^ $ v+' ,
��• Hl4,2 r '` . s Ft ,r ,F ;, a st 1:O
aa� 1 liteitittl: '.• „� a ..�,a . . , . . , %.t§ .. ..i.,�3 s " fi
Inappropriate Sexual
Behavior O O O O O O O
Disruptive Behavior
❑ ❑ ❑ O O O O
Delinquent Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ O O
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ O O O ❑ ❑
Eating Problems
❑ ❑ ❑ O O O O
Boundary Issues
❑ O O ❑ O O ❑
Requires Night Care
❑ ❑ O O ❑ ❑ ❑
Education
❑ O El O O O ❑
Involvement with Child's
Family ❑ ❑ O ❑ O ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 172 ❑ 2 ❑ 2''/ ❑ 3 ❑ 31/2
7
Weld County Addendum to the CWS-71
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
^ � a { } l
? .iy- to e�
N E"v
' I ti 453
Aqe 0-10...$16.32/day ($496/month)
County Basic tri Age 11-14...$18.05/day ($549/month)
Maintenance
Rate `,41 Age 15-21...$19.27/day ($586/month)
rel
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 112 s 4.66 Respite Care
app Total Rate=($23.67 day/$720 month)
341 $26.30
2it 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 131 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 112 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
C 3 $39.45
TRCCF Drop Down +$66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
• IE ILa SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
BY: L�.�i is_ ' ���,. ,.,ti `s"'- B
Deputy erk to the ' d, $ 7 Chair Sig ature
AUG 102011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Erbacher, Dan and Bailie
OF HUMAN SERVICES 3850 Cheyenne Dr
Greeley, CO 80634
By: BY: :kYt
p�'rector / /
(J By: //A; Cabe, ..—/
//-a/2
9 Weld County Addendum to the CWS-7A
LWS-/A(1(10-10/99)
r INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT ?pjj 19 /sty 9
1. THIS CONTRACT AND AGREEMENT, made this datg. y /`f. a,0(/ by and between $y
the Board of Weld County Commissioners, sitting as t oard of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Erbacher, Dan and Hallie, Provider ID# 1546381, 3850 Cheyenne Dr, Greeley, CO 80634,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
l.WS-S-/A(KIU-IU/Y9)
1J. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
cwa-/A(KIU-IWW)
4 To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the La
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
0 t ,` OUNTY DEPARTMENT OF HUMAN
J� ERVICES
int
r It61 �1 h_a
By:
Deputy •perk to the Boar U ">0 Chair Sign ure
Approval as to Substance: PROVIDER AUG 10 2011
WELD COUNTY DEPARTMENT Erbacher, Dan and Hallie
OF HUMAN SERVICES 3850 Cheyenne Dr
Greeley, CO 80634
By: By: an
irector '/
By: l.� SSA&LA--
.
3
&O0/i- /9�
CWS-/A(KIU-10/99)
•
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, 7/// by and between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Fisher, Matthew and Claire, Provider ID# 1532312, 5022 W 2nd St Rd, Greeley, CO 80634,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
cRC//-,07/7/ip
CMS-/A(KIU-IU/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
LWJ-/A(KIU-IU/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County C rk to th:lt\ EWELD CUNTY BOA OF RVIC OS, ON B HALF OF TH (
E WELD
COUNTY DEPARTMENT OF HUMAN
dd -, SERVICES
Ipli
By B . !LI
Depu'Clerk to the B�; � Chair Signature
AUG 10 2011
Approval as to Substance: '�°�"� PROVIDER
WELD COUNTY DEPARTMENT Fisher, Matthew and Claire
OF HUMAN SERVICES 5022 W 2nd St Rd
Greeley, CO 80634
By: By: c 9 .. /1
it ctor
By: ilirtr
3
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Fisher, Matthew and Claire
and the
Weld County Department of Human Services
for the period from July 1, 2011 through June 30,2012.
The following provisions, made this / day of (J,, A, , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1532312. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
' PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 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 ❑l)One round trip a week ❑I''/)2 round trips a week
02)3-4 round trips a week. ❑2%)5 round trips a week 03)6 round trips a week
03%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required 01)Once a month ❑I%)Two times month
❑2)Three times a month ❑2'/)Once a week 03)Two times a week
❑3%:)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑l)Less than a'%hour per day 011/2) 1/2 hour a day
02) 1 hour a day 02 %) I'/:-2 hours per day 03)2'/:-3 hours per day
❑3'%:)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed 01) Less than 5 hours per week El%)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week
02)8 to 10 hours per week 02%) I I to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
Comments:
A I. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%)Face-to-face contact three times per month with child and occasional crisis intervention.
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) ❑1) Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
�. Please rate the behavior/intensit of conditions which create the need for services that a..I to this child.
cg R ::-'` '11,.. .. ' ' -::: :i i
`" '?° '` tr>s ., ., . .... .,t. aY. 'a3 ' v v't"". .°'e,+ ax: `o.: .n
Aggression/Cruelty to
Animals ❑ ❑ ❑ ❑ ❑ O ❑
Verbal or Physical
Threatening ❑ O O O O O O
Destructive of
Property/Fire Setting O O O O O O O
Stealing
❑ ❑ ❑ ❑ ❑ ❑ ❑
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
Runaway
❑ O O O O O O
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (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.is I to this child.
as
`Cv. r� . xis*, 'q, x "M
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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
❑ O O O O ❑ O
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ O O O O O
Education
❑ ❑ 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 ❑1 ❑ 1'/2 ❑ 2 ❑ 2'h ❑ 3 ❑ 31/4
7
Weld County Addendum to the CWS-71
• (Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
mss„ a ua
� � ' 5k
t "`�'' �' e ?, ' -� ;{s%ty-xa
4 t Jy
A•e 0-10...$16.32/da $496/month
4!i
County Basic a Ixj A.e 11-14...$18.05/de $549/month
Maintenance §^'
Rate ?. A•e 15-21...$19.27/da $586/month
+Res•ite Care$.66/da $20/month
{ $19.73
1 +; $.66 Respite Care
Total Rate= ($20.39 day/$620 month)
`., . $23.01
1 112 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Hx;
Total Rate=($30.25 day/$920 month)
$32.88
3 ! +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
l�3
$36.16
3 1/2 a +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-71
•
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 S La� COUNTY DEPARTMENT WELD
•
F HUMAN
�R SERVICES
61
By: : ��Lia"!. �.� : i.• .. By: / /4O
Deputy !/erk io the Chair i nat
`..rr,,►� 10 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Fisher, Matthew and Claire
OF HUMAN SERVICES 5022 W 2nd St Rd
Greeley, CO 80634
BY: BY: ` — � „A ✓
Dir ctor
By: !'�L----
aC//-aig6
9 Weld County Addendum to the CWS-7A
LWJ-/A(RIU-IU/99)
• - INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS„gQNTTH�AcT Al spEa EM ENT, made this date, >//// by and between
the B &Mlveid'County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Foster, Denise, Provider ID#1551571, 10656 Bald Eagle Circle, Firestone, CO 80504,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
�C//- l /2
UN/S-/A(KIU-IU/99)
1+_ To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
GWS-/A(K1U-I111”)
4. , To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the WELD COUNTY BOARD OF SOCIAL
La SERVICES, ON BEHALF OF THE WELD
• COUNTY DEPARTMENT
EPARTMENT OF HUMAN
E•
/ 11,61 !iiN� •_
Depu . lerk to the Boar' '?t US Chair Si aturg,�
AUG 10 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Foster, Denise
OF HUMAN SERVICES 10656 Bald Eagle Circle
Firestone,on CO 80504
By: By: ritvLio,.. .
irector
By:
3
ao// j 9,
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Foster, Denise
and the
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 EC, , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1551571. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
aoi�-
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week DI)One round trip a week 01%)2 round trips a week
02)3-4 round trips a week. ❑2''/)5 round trips a week 03)6 round trips a week
03%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
O Basic Maint.)No participation required 01)Once a month ❑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
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1) Less than a''/I hour per day 01%) 1/2 hour a day
02) 1 hour a day 02 %:) I''/3-2 hours per day 03)2'/,-3 hours per day
03%)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) II to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
02) 8 to 10 hours per week 02%) 1 I to 15 hours per week ❑3) 16 to 20 per week
❑3%:)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
DI)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'%) Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the CWS-7/
(Example only do not complete) (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.
v
z...•'.47:71.•.° ,xg;..P. ,: ... , ;a '" x: ' � ". .
Aggression/Cruelty to
Animals ❑ 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 O
Substance Abuse
❑ ❑ ❑ ❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ O O O O O O
Enuresis/Encopresis
❑ O O O O O O
Runaway
❑ ❑ O O O O O
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-71
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
pp Please rate the behavior/intensit of conditions which create the need for services that a..I to this child.
'"" ' i Mfr , . . a• y
i ,, tG k4� W
y. P
k� a t t.. • S . f
1 k F 3 . a . h ':: K r t " ° -.''7 t
k k st°:,4t I '.: " '! K:; yn xn y a . .L ;1
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 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 ❑ 1'h ❑ 2 ❑ 2% ❑ 3 n31/4
7 Weld County Addendum to the CWS-7A
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
t � M1t d r
° T '•! '.`6 Fi& �3 1N
A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/de $549/month
Maintenance
Rate A.e 15-21...$19.27/da $586/month
+Res.ite Care$.66/da $20/month
$19.73
1 ` +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 112 , +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 p +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
�s-
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
�sr
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-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 then,, WELD COUNTY BOARD OF SOCIAL
S[[,a% SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
�aor. ERVICES
1861 �'1 *-4O •
��1
By. �1/ i �Z ��
Deputy Cerk to the Boa t► `).N1 Chair Si ature
AUG 10 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Foster, Denise
OF HUMAN SERVICES 10656 Bald Eagle Circle
Firestone, CO 80504
Il
By: By: t�1k/vu a�
irector
By:
aC//-fir',
9 Weld County Addendum to the CWS-7A
l.WJ-/A(KIU-I1d99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
t- THIS CONTRACT AND AGREEMENT, made this date, 7/3/1( by and between
th#, oa& o_� unt Commissioners, sitting as the Board of Social Services, on behalf of
�th83Wel f Mini?'nty Department of Human Service , hereinafter called "County Department" and,
Fritz, Nancy, Provider ID# 1539167, 3925 Stampede Dr., Evans, CO 80620, hereinafter called
"Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
(9O//—c2/`/` �c
I,WS-/A(KIU-IU/99)
, 11 _ To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
LW ,-/A(K I U-1 U/99)
, 4. _ To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
• IE 6e La� COUNTY DEPARTMENT OF HUMAN
SERVICES
1861 �• �a
Dep lerk toiv�'"�,9�' Chair Sign ure
Approval as to Substance: ®�`�ot PROVIDER AUG 1 0 2011
WELD COUNTY DEPARTMENT Fritz, Nancy
OF HUMAN SERVICES 3925 Stampede Dr.
Evans, CO 80620
By: By: �i y t
4Ccior4t
By:
3
��D// a7/9
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Fritz, Nancy 2011 JUL -8 A D 1 l
and the
Weld County Department of Human Services
for the period from July 1,2011 through June 30, 2012.
The following provisions, made this E2-5—day of 7-1,/ , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the'Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1539167. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
aoi/- < 2i)‘
1 Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
'PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System(FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week ❑I)One round trip a week ❑1%)2 round trips a week
02)3-4 round trips a week. ❑2'/i)5 round trips a week 03)6 round trips a week
❑3'/)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month ❑1''4)Two times month
02)Three times a month ❑2'/)Once a week ❑3)Two times a week
❑3'/:)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑I)Less than a '/2 hour per day 01%) '/3 hour a day
02) 1 hour a day 02 ''/) 1'h-2 hours per day 03)2''/-3 hours per day
❑3'/i)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 011/2)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
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming, physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'/i) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%z)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1/)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%:)Face-to-face contact three times per month with child and occasional crisis intervention.
03) Face-to-face contact weekly with child and occasional crisis intervention.
❑3'/x)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child
t t'# • a Gil
'"x 211 :...1. .�. " .,z ... . . , .. .. ,. ,, 4.",.$w. , . . :- _.. .. "w mP=teaa44.4‘ ��
Aggression/Cruelty to
Animals 0 0 0 0 ❑ ❑ ❑
Verbal or Physical
Threatening 0 0 0 0 0 ❑ ❑
Destructive of
Property/Fire Setting 0 0 0 0 0 0 0
Stealing
❑ 0 0 0 0 0 0
Self-injurious Behavior
❑ 0 0 0 0 0 0
Substance Abuse
❑ 0 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 ❑ ❑ 0 0
Enuresis/Encopresis
❑ 0 0 0 0 0 0
Runaway
❑ ❑ ❑ ❑ 0 0 0
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that a..l to this child.
4e 5.; • A•£ ;:::::,',,;t7;1;;;:31
4 ti'£A3§
1'+15. - . d 4
a3�4yM1�x
lld'. u ;v. .. .R, .. .' .. . , ,.S« t ,a;.u. „. . r:s �ry• a...,� .yvva,§.f;.•!..' mit
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 O
Depressive-like Behavior
❑ O O O O O O
Medical Needs
(If condition is rated"severe", O 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 O O O O O
Requires Night Care
❑ ❑ ❑ ❑ ❑ ❑ ❑
Education
❑ 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 ❑1 ❑ 11/4 ❑ 2 ❑ 2''/ ❑ 3 ❑ 3'/z
7 Weld County Addendum to the CWS-7A
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
V } #cx ��„re s.w�� t• a: a�T;yr,gym- v�� v� p
F i Ir r�td ALL �y,q`°� �k Fdo�}�, •' '3bn �t .y{t i A d ��yV�
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate t
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 112 ? +$.66 Respite Care
'NX Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
21/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 112 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$66 Respite Care
Total Rate=($40.11 day/$1220 month)
1t
Assessment/Emergency
Rate: $30.25 day/$920 month(Includes Respite)
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE s ada�� COUNTY DEPARTMENT WELD
F HUMAN
SERVICES
By: .�� i .[ i �h •� rte_ a j, -( St.,Deputy • erk to the :;. 4%U q�'I Chair Si ature
AUG 10 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Fritz,Nancy
OF HUMAN SERVICES 3925 Stampede Dr.
Evans, CO 80620
Q.---
By: By: -" ' Cn7 7i''�`C
Drector
By:
9 Weld County Addendum to the CWS-7A
L WS-/A(KIU-1U/V9)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT IInn.
1. THIS CONTRACT AND AGREEMENT, made this date, 2/// '7 8 A ^6yiaad between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Froggatte, Samuel and Rachelle, Provider ID# 1601426, 213 N 52nd Ave, Greeley, CO
50634, hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
I,WJ-/H (KIU-IU/YY)
11., To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
U W J-/H(K I U-I U/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County C = k to th C L 5 , WELD COUNTY BOARD OF SOCIAL
.7 SERVICES, ON BEHALF OF THE WELD
s 0 , COUNTY DEPARTMENT OF HUMAN
/ e't
��'%-.ric
SERVICES
It61 `
'vio�
Deputy�'erk to the Bo:%C lt' Chair Sign ure
Approval as to Substance: PROVIDER AUG 1 0 2011
WELD COUNTY DEPARTMENT Froggatte, Samuel and Rachelle
OF HUMAN SERVICES 213 N 52nd Ave
Greeley, CO 50634
By: /6 OBy
59
D rector
i By:
3
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreem_g,nt")�between -
Froggatte, Samuel and Rachelle LUI JUL -8 A C IS '
and the
Weld County Department of Human Services
for the period from July 1, 2011 through June 30, 2012.
The following provisions, made this ( day of 34 , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the/Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1601426. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A S-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (F1DOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
•
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.) Less than one round trip a week ❑1)One round trip a week ❑1'/)2 round trips a week
02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week
❑3%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required 01)Once a month ❑1'/)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3'/:)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑I)Less than a %hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 /) 1'/z-2 hours per day 03)2'/z-3 hours per day
03%) More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 011/2)5 to 7 hours per week
02)8 to 10 hours per week ❑2%z) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond a¢e appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week
02)8 to 10 hours per week 02%) I 1 to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑I)Face-to-face contact one time per month with child and minimal crisis intervention.
❑i%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑l) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the CWS-71
(Example only do not complete) (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.
1. ;
; t 'i�r .2 - ... t a ; - a ;
{ v
ti yr Aggression/Cruelty to
Animals El O O O O O O
Verbal or Physical
Threatening ❑ O ❑ ❑ ❑ ❑ ❑
Destructive of
Property/Fire Setting O O O O O O O
Stealing
❑ O O O O O ❑
Self-injurious Behavior
❑ O O O O O O
Substance Abuse
❑ ❑ ❑ ❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions O O O O O O O
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ O O O O O O
Sexual Offenses
❑ ❑ ❑ ❑ ❑ O O
6 Weld County Addendum to the CWS-71
(Example only do not complete) (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..I to this child.
44+:u
:'', s '".-7.;''',. rx+ a ss" :x5aw 1€
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
Depressive-like Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe", ❑ 0 0 0 ❑ 0 ❑
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ ❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ 0
Boundary Issues
❑ ❑ ❑ ❑ ❑ 0 0
Requires Night Care
❑ ❑ ❑ ❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
Involvement with Child's
Family 0 0 0 0 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2%2 ❑ 3 O31/2
7 Weld County Addendum to the CWS-7P
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
a a�7t yr
, ,
...: ,t.-;. X13 ,�.,�: .' t4v» .? .. a,._„ .�...:�.�.,,a °�:,_s
+ki
Age 0-10...$16.32/day ($496/month)
County Basic `: Age 11-14...$1•
8.05/day ($549/month)
Maintenance .
Rate (`_, Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 + e
Total Rate=$,66($23R.67spite Care day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
vzt 21/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
_ Total Rate=($33.54day/$1020 month)
t
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1.120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
CWS-7/8 Weld County Addendum to the
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 dR!.'�t. WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
1161 �
•
p tW
By., %J/ /-� � 1�� �i♦a,_.,�/fiL'Lp�
Deputy " erk to the Bo? . . � Chair Si nature
AUG 1 0 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Froggatte, Samuel and Rachelle
OF HUMAN SERVICES 213 N 52nd Ave
Greeley, CO 50634
By: By:
Di ector
By.
9 Weld County Addendum to the CWS-7A
LWS-/A(KIU-IU/YY)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, 7/g/ 1 1 2811 `�-ay �� b
the Board of Weld County Commissioners, sifting as the Board of Social Services, on behalf of
so
the Weld County Department of Human Services, hereinafter called "County Qepartment" and,
Gariepy, Susan J, Provider ID#1553740, 5151 W 29th St#1706, Greeley, CO 80634,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
i ?0//-o2/2,
LWS-/A(KIU-10/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
L W S-/A(1t10-10/99)
.4, To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the By�,�. WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
R �.vry
By: ill _ii1/.!_' i •�� i Ir +1? A��/1.-- J 2.>
Deputy ' lerk to the :•`!. ~ Chair Sin ure
Approval as to Substance: PROVIDER AUG 1 0 2011
WELD COUNTY DEPARTMENT Gariepy, Susan J
OF HUMAN SERVICES 5151 W 29th St#1706
Greeley,--CO
80634
By: By: �44'"6
Dir ctor
By:
3
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreeme '') between
Gariepy, Susan J a 14 TO IQ $Q
and the
Weld County Department of Human Services
for the period from July 1,2011 through June 30, 2012.
The following provisions, made this 7 day of J v I , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1553740. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
a?C//— /9
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
' PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System(FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week ❑1)One round trip a week 01%)2 round trips a week
02)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week
❑3'/a)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required DI)Once a month ❑1'/i)Two times month
02)Three times a month ❑2%)Once a week 03)Two times a week
❑3'/)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1)Less than a'/x hour per day 01%) 1/2 hour a day
02) 1 hour a day 02 ''/) 1'/z-2 hours per day 03)2'/,-3 hours per day
❑3'%) More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1'/)5 to 7 hours per week
02)8 to 10 hours per week 02%) 1 I to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond 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 011/2)5 to 7 hours per week
02)8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3'/)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
DI)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'/)Face-to-face contact one timeper month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
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 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that at I 1 to this child
4q '
;G�liti i.x af. "c"-..d."` . .,.. .....� v. ?'rx4...... '.... _+s: •. a .dv. .. raise ". n..n 1 =w a .,e" "°' ...i
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
❑ ❑ ❑ ❑ ❑ ❑ ❑
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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑ O O O
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
• ' WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that al II to this child.
* M
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior
❑ 0 0 0 0 0 0
Depressive-like Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe", 0 0 0 0 0 0 0
please complete the Medically
fragile NBC)
Emancipation
❑ 0 0 0 0 0 0
Eating Problems
❑ 0 0 0 0 0 0
Boundary Issues
❑ ❑ ❑ ❑ ❑ ❑ ❑
Requires Night Care
❑ 0 0 0 0 0 0
Education
❑ ❑ ❑ ❑ 0 0 0
Involvement with Child's
Family 0 0 0 0 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 11/4 ❑ 2 ❑ 2'/z ❑ 3 ❑ 3%
7 Weld County Addendum to the CWS-7A
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
n „ r
a fr # h } k + £ ••r .:.4'3R �, •
•
A•e 0-10...$16.32/da $496/month
County Basic S�"`.`1
P7- . A.e 11-14_.$18.05/da $549/month
Maintenance :i•
�,{
Rate A.e 15-21...$19.27/da $586/month
+Res•ite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 a +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
iftl Total Rate=($26.96 day/$820 month)
$29.59
21/2 +$.66 Respite Care
r..1.r+ Total Rate=($30.25 day/$920 month)
mm?
$ $32.88
3 +$,66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down !. +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk WELD COUNTY BOARD OF SOCIAL
_ a SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
1861tat?g
SERVICES
%JiAI�
By: i� � � �a11:!► � !/iJ�a t / B G/
Deputy 'erk to the Boar t'�__� Chair ignature
AUG 10 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Gariepy, Susan J
OF HUMAN SERVICES 5151 W 29th St#1706
Greeley, CO 80634
By: By.
irecto
By:
C//- ) ?
9 Weld County Addendum to the CWS-7A
CWS-/A(KW-IV/99)
• INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, 71/// by and between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Gerardy,Jerry and Priscilla, Provider ID# 1530549, 3408 Cody Ave, Evans, CO 80620,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hers.
Fowl
c..
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider. ety
2. To safely provide the 24-hour physical care and supervision of each child until removd or until
the agreement is renewed.
Oi
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
CWS-/A(K IU-IU/99)
it. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
23
19. Not to enter into any subordinate subcontract hereunder.
c-
20. To keep such records as are necessary for audit purposes by state and federal personnEl The
records shall document the type of care and the term during which care is provided forh child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements. -o
21. To maintain medical, dental and educational records for each child/youth and supply uped
information to the County Department. Gd
C,
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
LWS-/A(KIU-IU/99)
4.. To give the provider a written record of the child's admission to the home at the time of
placement. .
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
0
ImaS
Please refer to the Weld County Addendum and `"
the child specific Needs Based Care Addendum to this agreement. c
ATTEST: Weld Count erk t Srda WELD COUNTY BOARD OF SOCIA
•
SERVICES, ON BEHALF OF THE D
e",,,� .% COUNTY DEPARTMENT OF HUM.rV
Ito � SERVICES to
/ --41;OS A
OJ
By: �� /. �AL� �i . �IT '� B 4&iit
Dep A' lerk to the Bpi,.. ''; Chair Sig, ture
AUG 1 0 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Gerardy, Jerry and Priscilla
OF HUMAN SERVICES 3408 Cody Ave
Evans, CO 80620
By
rector
By:
3
07c//- 6771 2‘,
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Gerardy, Jerry and Priscilla
and the
Weld County Department of Human Services
for the period from July 1, 2011 through June 30,2012.
The following provisions, made this ( day of is , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the/Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1530549. These services will be for children who have been deemed eligi for
social services under the statutes, rules and regulations of the State of Colorado
r-
3. All bed hold authorizations and payments are subject to a 3 day maximum fon.a.child's
temporary absence from a facility, including hospitalization. Bed hold requesCemust
have prior written authorization from the Department Administrator before payment will
be release to Provider. �..
4. Any additional costs for specialized services, which may include but are notated to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
ac//-2/94
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrects:ins in
performance are satisfactorily completed; f ,
w
B. Deny payment or recover reimbursement for those services or deliverales which
have not been performed and which due to circumstances caused by tI Provider
cannot be performed or if performed would be of no value to the Hump Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be ,viewed on
a monthly basis and signed off by child's caseworker and/or the provider's later Care
Coordinator. c—
c
r
10. Maintain/update medication logs on a daily basis, if child is taking medicatis.
11. Maintain behavior observation notes as required by the level of care assesse 'or each
child.
N
12. Assure and certify that it and its principals: c
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
C-
r
c4
W
as
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1'/:)2 round trips a week
02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week
❑3%:)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month ❑1'/:)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3'/:)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1)Less than a '/:hour per day 011/2) 1/2 hour a day
02) 1 hour a day 02 %x) 1'h-2 hours per day 03)2'/2-3 hours per day
❑3'/i)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3'/)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond aee air ropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
c.-
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 tt hours per week
❑2)8 to 10 hours per week ❑2%:) 11 to 15 hours per week ❑3) 16 to1,p per week
❑3%)21 or more hours per week W
Comments:
'D
A 1. How often is CPA/County case management required?(Does not include therapy) t,,,,
fV
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. ce
(i.e.mutual care placements.) Cr)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
011/2)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the CWS-7P
(Example only do not complete) (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.
'
♦u+�ery
vn --4";",.."..";1:',":'-'..'..",':..
rkv _ . : � '.'''" .rr. .J
.Y ....wrt 1 3
Q �
d4
`Es.₹_.'`'.,.v t; e.,.. w -. .. :rr . ...': ...., ..X+,_.x.w+w„.t 'axwtc..+_. .. :'. .. ' :e,..w.R.� .2 ea.`.v''t47-5..i ii .uu 'a,
Aggression/Cruelty to
Animals ❑ 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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Substance Abuse
❑ O O O O O O
Presence of Psychiatric
Symptoms/Conditions O O ❑ ❑ ❑ ❑ O c
r
w
Enuresis/Encopresis
❑ ❑ ❑ ❑ O O O
Runaway
❑ O O O O O O
Sexual Offenses
❑ ❑ ❑ ❑ ❑ O O
6 Weld County Addendum to the CWS-7/
(Example only do not complete) (Exhibit B)
' - WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child.
- si....:
-' 1 w s vIT,t 's
'r i} k :,...:.,•'" :• ,s.•., -(1°.' k £}
k } :Ny i } .. .. fx42; a 4A14,£. '
Atlet-b'* 3ti �4'°4 4 tlY xrk i '. ;- £ds x'A. ''i. .b
Y i • j . ti { �
t..:xi ..v ..xi w.4�1`d ....r e: .xr .: ,. ..,:x.r."y-":a4...,,4+§. :•...•,e. .... : ..', ; _v.. .�. ....k'pic ...
Inappropriate Sexual
Behavior O O O O O O O
Disruptive Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Depressive-like Behavior
❑ O O O O O O
Medical Needs
(If condition is rated"severe", ❑ ❑ O O O O O
please complete the Medically
fragile NBC) L
4—
I—
Emancipation
❑ ❑ ❑ ❑ ❑ ❑ W ❑
'-S
Eating Problems
C,
Boundary Issues
❑ ❑ ❑ ❑ ❑ ❑ ❑
Requires Night Care
❑ O O O O O O
Education
❑ ❑ ❑ 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 ❑1 ❑ 1'1/2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'/z
7 Weld County Addendum to the CWS-7/
,(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
• >y w '
F
iM' i sat i � x"�
a..., +' '
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance P
Rate
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$,66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1112 :1;
+$.66 Respite Care
Total Rate=($23.67 day/$720 month)
e�t1
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
21/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month) r"
$36.16 31/2 +$.66 Respite Care F-+
Total Rate=($36.82 day/$1,120 month) CJ
4 $39.45
TRCCF Drop Down +$.66 Respite Care 1-+
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency _
Rate $30.25 day/$920 month(Includes Respite)
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
Es La SERVICES, ON BEHALF OF THE WELD
�°L. �` COUNTY DEPARTMENT OF HUMAN
SERVICES
ld i1
By: !%�yii.i i . '_�. t a . •
Depu lerk to the
Chair Si nature
AUG 1 0 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Gerardy, Jerry and Priscilla
OF HUMAN SERVICES 3408 Cody Ave
Evans, CO 80620
By: By.
i ector
Byi
0
L
r--
1-4
C.)
N
V
(2L'//- ,Q
9 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
2011 JUL 19 API 10 51
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Hess,John and Betty
and the
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 i.(ti
, 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1599444. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
• but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 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?
OBasic Maint.) Less than one round trip a week ❑1)One round trip a week ❑1%)2 round trips a week
02)3-4 round trips a week. /OVA)5 round trips a week 03)6 round trips a week
❑3''/) 7 round trips or more
Comments:, 3(2400,0
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
O Basic Maint.)No participation required CIO-Once a month O1%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
03%)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
11 Basic Maint.)No educational requirements O1)Less than a ''/3 hour per day O1%)1/2 hour a day
❑2) 1 hour a day 02 %) I'%-2 hours per day 03)2'/-3 hours per day
❑3%i More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed O1)Less than 5 hours per week Of%)5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week /
❑3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
-PU Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week O1%)5 to 7 hours per week
❑2) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3'%i 21 or more hours per week
Comments:
A I. How often is CPA/County case management required? (Does not include therapy)
,Lalais Maint.)Face-to-face contact one time per month with child and no crisis intervention.
s (i.e.mutual care placements.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
O1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) jailiess than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
•
WELD
NEEDS BASED
COUNTY CAREDHS BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child
,U t"4---1.,,
pry t i � tl,�"E"�rxx
.fit *9 �. 'ti x F4. r . .....f"'::\....,-;.;;F-:-; t R
il. ...aar� .f.s'n'.` ,..t.. ,.s._ .e ;`r , .r$srv. ,-4: "` . t. .. .� ,,,,, a. se:
`k 9:3.. .:i^...x ..m co-M=._skeq.v.zi?...S
Aggression/Cruelty to
Animals 0 ❑ ❑ 0 ❑ 0
Verbal or Physical
32/
Threatening 0 ❑ 0 0 0 0
Destructive of
Property/Fire Setting gal0
0 0 0 0 0
Stealing
❑ 0 0 0 0 ❑
Self-injurious Behavior
❑ 0 0 0 0 0
Substance Abuse J
,e( 0 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ 0 0 0
Runaway /
Sexual Offenses
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that a.el to this child
Y
Inappropriate Sexual / 0
0
❑ 0
0
0
Behavior ✓VI
Disruptive Behavior
0 0 0 0 0 O
Delinquent Behavior
o ❑ ❑ ❑ ❑ ❑
Depressive-like Behavior
❑ O O O O O
Medical Needs
(If condition is rated"severe„", ❑ O O O O O
please complete the Medically
fragile NBC)
Emancipation Ir1. B. /1 Ord
❑ O O O O O O
Eating Problems
❑ ❑ , O O O ❑
Boundary Issues ����
❑ i O O O O O
Requires Night Care /
p/ O O O O O O
Education
O O O O O O
Involvement with Child's 1,015 Gird
Family O O O O ❑ O Mkt Aillg✓,
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'/2 ❑ 2 ❑ 2Y2 ❑ 3 ❑ 31/4
7 Weld County Addendum to the CWS-7A
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
e zqv ° r a1 `� 1
. .^�se
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate r
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
PitT
2 1/2 A3h +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 112 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
44.
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
• 'IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTESTa Co to the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
IEZA, SERVICES
•
BY legF1♦� By. dhb
De o ,ty Clerk to t' �t : %,i.�`� �� Chair S' nature
® AUG 102011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Hess, John and Betty
OF HUMAN SERVICES 311 25th Ave Ct
Greeley, CO 80631
By: By: 6.-Ay//114‘2—
i
ector � v 1 Q�
By: cJ�.�"r/i"7
1464
(3?C//- c)
9 Weld County Addendum to the CWS-7A
I:WS-/A(KIU-10/99)
. "A INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, 7//// 2mi in and between
the Board of Weld County Commissioners, sitting as the Board of Social Ss►,t11n al*?
the Weld County Department of Human Services, hereinafter called "County Department aliB,' 10 51
Hess, John and Betty, Provider ID# 1599444, 311 25th Ave Ct, Greeley, CO 80631,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
LWS-/A1KIU-1U/99)
1. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
LWJ-/A (KIU-IU/99)
- ;l. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
/rya COUNTY DEPARTMENT OF HUMAN
SERVICES
1861 t Ikcs
By: B6(1.1/4(1.1/4 21/1.itputy Clerk to r� 3�a` Chair Si ature•
nn ill
Approval as to Substance: � !L'll�� PROVIDER AUG 1 0 2011
WELD COUNTY DEPARTMENT Hess, John and Betty
OF HUMAN SERVICES 311 25th Ave Ct
Greeley, CO 80631
By: By:
Di ctor
By:
3
C//-07/2
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Hernandez, Roberto and Margarita
and the
Weld County Department of Human Services
for the period from July 1,2011 through June 30, 2012.
The following provisions, made this j day of Dili' , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1520297. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
(9 C//-62/94
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week 01)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
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required 01)Once a month O1%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3%)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1)Less than a''/3 hour per day 01%) 1/2 hour a day
❑2) 1 hour a day 02 '/:) I'h-2 hours per day ❑3)2'/,-3 hours per day
03%)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week
O 3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'/:) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%) Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03) Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (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. II
, ,r
yq,,';�-fi 4 44,,
F .. .. xi Ova "4 ems"^'
fin..
* T # r ;V '1114,..•-:..L.,rittlaWiltar94.'65
rgittlik
Aggression/Cruelty to
Animals ❑ O O O O O O
Verbal or Physical
Threatening ❑ O O ❑ ❑ O O
Destructive of
Property/Fire Setting O O O O O O O
Stealing
❑ ❑ 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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
• NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
riarey, Please rate the behavior/intensit of conditions which create the need for services that q..1. to this child.
°l, ;i 4 4
t
,,,::::Iiiiifitiet:;",,,
�enWjWrv .{"^ 6 f" 4u �.
3.0 . aa *o`.,:i6 - . r . .. as.,.- st(R.,x.,n, . . , ..._..x.. '�'', -tixa �. �,_
Inappropriate Sexual
Behavior O O O O O O O
Disruptive Behavior
❑ O O O O O O
Delinquent Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Depressive-like Behavior
❑ O O O O O O
Medical Needs
(If condition is rated"severe", ❑ O O O O El O
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ O O O O
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues
❑ O O O O O O
Requires Night Care
❑ ❑ ❑ ❑ ❑ ❑ O
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
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 ❑1 ❑ 11 ❑ 2 ❑ 2% ❑ 3 ❑ 3%
7
Weld County Addendum to the CWS-7A
• (Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
Rn,,t s rot
h 533+ •
{ 5 S •
•
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
('t{= Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 112 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-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 OF THE WELD
COUNTY DEPARTMENT OF HUMAN
,IQ E L 'S SERVICES
By: . ✓ . c a:r" 1861 . A,ll J -(
De. ty Clerk to th• P' 4g;:` �i: . ' ' Chair ignature
fir. •
♦ �i \ AUG 1 0 2011
Approval as to Substance: � .111 PROVIDER
WELD COUNTY DEPARTMENT Hernandez, Roberto and Margarita
OF HUMAN SERVICES 912 Elm Ct
Fort Lupton, CO 80621
By: By:
Dir ctor
By:jyi(ypEr
C//C- /V
9 Weld County Addendum to the CWS-7A
LWJ-/A(KW-IU/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, 7//�/ by and between
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called"County Department" and,
Hernandez, Roberto and Margarita, Provider ID# 1520297, 912 Elm Ct, Fort Lupton, CO
80621, hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
QC)//-a?/ k
(K10-111/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
1,W J-/A(K I U-I V/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
pELa SERVICES
By: / e / 1661 { S�wo . S .
De ty Clerk to th .,01 ' r Chair Si• ature
AUG 10Z011
Approval as to Substance: et PROVIDER
WELD COUNTY DEPARTMENT � Hernandez, Roberto and Margarita
OF HUMAN SERVICES 912 Elm Ct
Fort Lupton, CO 80621
By: c 4 6-,A1 By:
hector r
1 By: /l,,rir. ia
3 C O
20//-02/9
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Hernandez, Paul and Catherine
and the
Weld County Department of Human Services lUt 11 ,gm 10 y9
for the period from July 1, 2011 through June 30, 2012.
The following provisions, made this //lay of , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms t greement remain unchanged.
GENERAL PROVISIONS
County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1604640. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
9C//- 02/74
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended,proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public(federal, state, or local) transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week ❑l)One round trip a week ❑1'/)2 round trips a week
02)3-4 round trips a week. ❑2'/:) 5 round trips a week 03)6 round trips a week
❑3%:)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑l)Once a month ❑1%:)Two times month
02)Three times a month ❑2'/:)Once a week 03)Two times a week
❑3%)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑l)Less than a 'h hour per day 01%) 1/2 hour a day
❑2) 1 hour a day 02 1/2) 1'/,-2 hours per day 03)2''/-3 hours per day
❑3'/i)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed O1)Less than 5 hours per week ❑I'/)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) 11 to 14 hours per week
0 3)Constant basis during awake hours ❑3%:)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%:) II to 15 hours per week ❑3) 16 to 20 per week
❑3'/)21 or more hours per week
Comments:
A I. How often is CPA/County case management required?(Does not include therapy)
['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑l)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3'/:) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (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.
a g2 tee 1 ,� x Y it�itt�t��a ' „h tfi daF§
rt I dy n ₹ f fi 6 Il I I 5
fi s}±T I 1 i xi
' � I tea s `. °et fr r #' 7 ..
� tu0 � n� ut �t`€r k , *y �a•.�} �� s��sr� sc . .
Aggression/Cruelty to
Animals 0 0 ❑ ❑ 0 0 El
Verbal or Physical
Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑
Destructive of
Property/Fire Setting 0 ❑ ❑ ❑ ❑ El ❑
Stealing
❑ ❑ ❑ ❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ 0 0 ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ 0 ❑ ❑ ❑
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (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.r 1 to this child.
1 ) ? 1 V 4 b
� ar+ 3;��1X��x ¢. :rst Vii. =( u4<=i� rcsdtt¢e�. i .x",(,.'t...a-Sfs� Yc?.sswva,. 55".W ..,r�F,--;f ..ta; ' " ,.,
Inappropriate Sexual
Behavior ❑ O ❑ ❑ ❑ O O
Disruptive Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ O O O O O
Depressive-like Behavior
❑ ❑ ❑ El O O ❑
Medical Needs
(If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ O ❑ O ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ O O O ❑ O
Requires Night Care
O ❑ O O O O O
Education
❑ ❑ O ❑ ❑ ❑ ❑
Involvement with Child's
Family ❑ O ❑ O O ❑ O
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2/ ❑ 3 ❑ 3'h
7 Weld County Addendum to the CWS-7A
(Exhibit C)
•
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
•
Age 0-10_.$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate •
Age 15-21...$19.27/day ($586/month)
):.': +Respite Care$.66/day ($20/month)
$19.73
1 +166 Respite Care
`K'" Total Rate= ($20.39 day/$620 month)
$23.01
1 112 c +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 ` 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 112 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 112 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
•
4 .'a $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
AssessmentiEmergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
• ' IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
iii' SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
f \\ E L SERVICES
E
By: - / )f test ( : to:: • / y.�
ag`
Dep 4 Clerk to the : .: ir Chair S' nature
.,.
® / AUG 1 0 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Hernandez, Paul and Catherine
OF HUMAN SERVICES 1858 Twin Lakes Circle
Loveland, CO 80538
9
By:- By: t-1/4/
D rector
By:
0?(// /
9 Weld County Addendum to the CWS-7A
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1011 JUL 19 in 7�rr�� 11���
1. THIS CONTRACT AND AGREEMENT, made this date, 7////i by andlktwhlEn
the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Hernandez, Paul and Catherine, Provider ID# 1604640, 1858 Twin Lakes Circle, Loveland,
CO 80538, hereinafter called"Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
c200//- o7/5
-11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
4. To give the provider a written record of the child's admission to the home at the time of
! placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to th- Board WELD COUNTY BOARD OF SOCIAL
�j. SERVICES, ON BEHALF OF THE WELD
�°OCOUNTY DEPARTMENT OF HUMAN
%S RVIC S
• X861 I.;s {'y
By: 9IJ I iI �I� .����/� AQ{[ /Ud-/
puty Clerk to th• Bo. " Chair Sig ature
4f AUG 1 0 2011
Approval as to Substance: %%� � PROVIDER
WELD COUNTY DEPARTMENT Hernandez, Paul and Catherine
OF HUMAN SERVICES 1858 Twin Lakes Circle
Loveland, CO 80538
By: By: _—
DA4CLri
By: l e
3
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Heimer, Sara
and the
Weld County Department of Human Services
for the period from July 1,2011 through June 30,2012.
The following provisions, made this 2-% day of — , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the A ement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1547292. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services,which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid,will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
c//-0:7/9 .
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider,within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not,within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain,or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement,had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan?
asic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1'/:)2 round trips a week
2)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week
03%)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required DI)Once a month 01%)Two times month
❑2)Three times a month W2'/:)Once a week 03)Two times a week
❑3'/z)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
Basic Maint.)No educational requirements ❑l)Less than a''/z hour per day 01%)1/2 hour a day
❑2) 1 hour a day 02 %) 1'/-2 hours per day 03)2%z-3 hours per day
❑3'/z)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1%)5 to 7 hours per week
8 to 10 hours per week 02%) 11 to 14 hours per week
O 3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/:)5 to 7 hours per week
2)8 to 10 hours per week ❑2'/) I I to 15 hours per week 03) 16 to 20 per week
❑3%)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
// `` (i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑11)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services. .
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
J )Not needed or provided by another source(i.e. Medicaid) ❑i)Less than 4 hours per month
9\n_s 1......c nay rnnntb fniA 0_10 k...,..o...,nno,
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
..rtw.�� ,.:;`y' c,� 4uctSPtL � d "S a.v f
x"�: , �,�� Rtl> g of Condition. x , t,tv
r.
e-
•„€ :,< ': w a bogy[for each f
1 k
.'., :+-: - '-a' v`• .T F. + moderate n✓ro
f 15,
.. sm P ,--1':,:''. . -
I 1 1 2 21/2 3 )`t .
Aggression/Cruelty to
Animals V O O El O ❑
Verbal or Physical
Threatening IQ( 00 O O O O
Destructive of
Property/Fire Setting )4 O El O O O O
Stealing
El O O O ❑ El
Self-injurious Behavior
A O O O O O 0
Substance Abuse
;2( El ❑ ❑ O ❑ El
Presence of Psychiatric
Symptoms/Conditions )4 O 0 ❑ El ❑ ❑
Enuresis/Encopresis
A El O El ❑ O O
Runaway
IA El ❑ O O O El
Sexual Offenses
it O O El El O O
(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 ap J'to this child.
:"1. .'..1,:'.:-..,(-:.73 :-,-50t,,.., ....a T z¢/ tr' ;°t.,u,,r c. r1'a ♦ d of • r�{�a"t; .tdF ,��j �..�r
-2,,, .1:: 17..,,,6,..4.:..._ : „. ' xy .: l�k box for each eaateso t� �.:�i,K�:.;,K � = �Y 5.. ,-,
�•S�•' i .cad.•?�a 'Lsti,Fr 2l v).'�}`• k _ •c•` __�.�,� :' �.•��+hi^•i���.�..:`'.^-..�i�'.
r..;•h. 7:O1,P x� �
S Y�`�-� e k\•
�:• �`1 • .�"r`�:5';A�`r?�'� , Mo*yri IiRIL MO 1
2
Inappropriate Sexual V 0
0
❑ ❑ ❑ ❑
Behavior
,
Disruptive Behavior
i ❑ ❑ ❑ O O ❑
Delinquent Behavior
Depressive-like Behavior
14 ❑ O O O O ❑
Medical Needs
(If condition is rated"severe", O O O ❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
A O O ❑ O O O
'
Eating Problems
X O ❑ ❑ ❑ O O
Boundary Issues
N O O ❑ O O ❑
r
Requires Night Care
❑ X.
O ❑ O ❑ O
r
Education
ekay ec Spe.ch ❑ ❑ )C ❑ ❑ O ❑ O
Involvement with Child's
Family 12k ❑ ❑ El O ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) El)( Ell El1'/ n 2 E 2'/2 ❑ 3 n 3'/z
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
RECOMMENDED
LEVEL OF SERVICE PROVIDER RATE
P1-PS
fait
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
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
L COUNTY DEPARTMENT OF HUMAN
%.ERVICES
1861
,
By: ' r%l/1 r� 1—i i Li 'i
.51u � eft ._ '�•
De X11 ty Clerk to th j:o` % ` Chair Si <ture
AUG 102011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Heimer, Sara
OF HUMAN SERVICES 3000 W 19th St
Greeley, CO 80634
By: By:
ctor
By:
CWS-7A(R I 0-10/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, 7-Z%— 11 by and between
the Board of Weld County Commissioners, sifting as the Board of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called"County Department"and,
Helmer, Sara, Provider ID#1547292, 3000 W 19th St, Greeley, CO 80634, hereinafter called
"Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30,2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
(9C/7-c--2/94
CWS-7A(RIO-10/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
• placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
CWS-7A s-7A(R10-10/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
•
By: ".` / ll� / .`k!
D:�'�uty Clerk to th=( an 1 y<< � Chair Sig ature
Approval as to Substance: C 1 , PROVIDER AUG 1 0 2011
WELD COUNTY DEPARTMENTHeimer, Sara
OF HUMAN SERVICES ®� �'�, 3000 W 19th St
Greeley, CO 80634
•
By: By: 1X-1 �- P 1 M.k.r-
Dir ctor
By:
3
cy/-07/ 4
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Hays, Stephen Dale and Chantel
and the
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 T..ky , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1587489. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A S-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week ❑1)One round trip a week ❑1%)2 round trips a week
02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week
❑3'/)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month 01%)Two times month
02)Three times a month ❑2'/)Once a week 03)Two times a week
03%)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1)Less than a 'h hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 %) 1'h-2 hours per day ❑3)2'/,-3 hours per day
❑3%)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) II to 14 hours per week
❑3)Constant basis during awake hours ❑3%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 011/2)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'%) II to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3% Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
DO)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a..I to this child
+ . °Mr t'_?. T: a 4�,:r`
rota # »gym- :s;' 4"• a ter;°'" t, ' :kiss
`mss °§, `a x.�. t " a '�b
..,....r a5ee. .�.c... .,.ee+.: .z:.. C.. .... ,....,:....,� av&*"rtti ,_ 4mff_.
Aggression/Cruelty to
Animals O ❑ O O O O O
Verbal or Physical
Threatening ❑ O ❑ ❑ ❑ ❑ ❑
Destructive of
Property/Fire Setting O O O O O O O
Stealing
❑ ❑ ❑ ❑ ❑ ❑ ❑
Self-injurious Behavior
❑ O O O O O O
Substance Abuse
❑ ❑ O ❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ O ❑ O O O O
Enuresis/Encopresis
❑ O O O O O O
Runaway
❑ ❑ ❑ ❑ O O O
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
• WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that al•I to this child.
,,n;:;:;'-'11.:;' ,.1.::
k�ia ;, _"ter°.'�,; '5 .: 4 F s } '+qsm p ��� 0 � Y.
• %ai't�.sil 4: .k:�. . ,.. .. . e . ._.:i6sat.#sa,.a,,..., . . .. .. . :. a a..t u Wiileit�,.
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', ❑ ❑ ❑ ❑ ❑ ❑ ❑
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
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
Involvement with Child's
Family 0 0 0 0 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 2''/ ❑ 3 ❑ 3'/z
7 Weld County Addendum to the CWS-7A
• (Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
.x u -Y„#.`.si ax3s�,�wa�3'`ee«bza k'4u iwax �'Asy���e`� �ti�kh�fk'.$'.. ✓»`^v
A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maintenance
Rate A.e 15-21...$19.27/da $586/month
Vet
+Respite Care$.66/da $20/month
$19.73
1irtt
+$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
Pti
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
FIS
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
u '
q,.
Assessment/Emergency , $30.25 day/$920 month(Includes Respite)
Rate
Effective 7/1/2008
8 Weld County Addendum to the CWS-7A
' ' ' IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
•
186I tsv
By: . : /
De i} y Clerk tot . Chair i nature
® ~ AUG 10 2011
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT Hays, Stephen Dale and Chantel
OF HUMAN SERVICES 229 4th Street
Fort Lupton, CO 80621
c�'�'--
By: By: .
))\-(ThE
it etor
By:r 1"tl,l'*hC Vi'
,i67/7_02/9 ,
9 Weld County Addendum to the CWS-7A
GWS-/A(KIU-IU/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date, -2//s/// by and between
the Board of Weld County Commissioners, sitting as the Board of ocial Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Hays, Stephen Dale and Chantel, Provider ID# 1587489, 229 4th Street, Fort Lupton, CO
80621, hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
mae//—a/3‘,
LWJ-/A(KIU-IU/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
LWS-/A(KIU-IU/99)
4, To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the Boa _ WELD COUNTY BOARD OF SOCIAL
,t ]EL N. SERVICES, ON BEHALF OF THE WELD
• ® \` COUNTY DEPARTMENT OF HUMAN
ERVICES
t 1861 =J A�4
By: .HI % !/Y
D_G uty Clerk to th c.a Chair Sign ture AUG 1 0 2011
Approval as to Substance: _. PROVIDER
WELD COUNTY DEPARTMENT Hays, Stephen Dale and Chantel
OF HUMAN SERVICES 229 4th Street
Fort Lupton, CO 80621
By: J By .
Dir for '�l~��`'� ^, .') / "
By: L�^�" llAk \AA/1Y
3
c-?G//- / 2�
WELD COUNTY ADDENDUM l JUL 15 HP! 101`1
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Gomez, Oswald and Christina
and the
Weld County Department of Human Services
for the period from July 1, 2011 through June 30,2012.
The following provisions, made this ( day of J , 2011, are added to the referenced
Agreement. Except as modified hereby, all terms of the greement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1588508. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
&O//-02/94
Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
• but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
2 Weld County Addendum to the CWS-7A
' PROVIDER SHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
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;
3 Weld County Addendum to the CWS-7A
•
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
4 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week 01)One round trip a week ❑1'/z)2 round trips a week
02)3-4 round trips a week. ❑2'/z)5 round trips a week 03)6 round trips a week
❑3%z)7 round trips or more
Comments:
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required 01)Once a month ❑1'%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3%z)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements DI)Less than a ''/z hour per day 01%) 1/4 hour a day
❑2) 1 hour a day 02 %) 1'/z-2 hours per day 03)21/4-3 hours per day
❑3%) More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed 01) Less than 5 hours per week ❑1'%)5 to 7 hours per week
❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'%)5 to 7 hours per week
02)8 to 10 hours per week 02%) I I to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention.
❑2'%) Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
5 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
•
WELD
NEEDS BASED
COUNTY CAREDHS BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a..l to this child.
;;;14::".r:•;,' t � ,�,�px�gat�..�y r�uahRX ,y.
S $
q +t_...°mkw��.a,.k.. '. . ...5..t.. P.. , ... ,e.. . y"
Aggression/Cruelty to
Animals 0 0 0 0 0 0 0
Verbal or Physical
Threatening ❑ O O 0 0 0 0
Destructive of
Property/Fire Setting 0 0 0 0 0 0 O
Stealing
❑ 0 0 0 0 0 0
Self-injurious Behavior
❑ 0 0 0 ❑ 0 0
Substance Abuse
❑ 0 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 0 0 0 0
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ El
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
6 Weld County Addendum to the CWS-7A
(Example only do not complete) (Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that a..l to this child.
m � # � ��a has a=,. �.
r X i
' fi v r :-kania h4irv3 i:n '. ..e k ..: ... . .. aS.a. . ... e, .�: �ia.av d�,"±.msW t \Y...e a. .- ?y4; _��°°.}.• �t-�'
Inappropriate Sexual
Behavior O O O O O O O
Disruptive Behavior
❑ O O O O O O
Delinquent Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Depressive-like Behavior
❑ O ❑ O 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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑ ❑ O O
Requires Night Care
❑ O O ❑ O O O
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
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 ❑1 ❑ 1'h ❑ 2 ❑ 2''/ ❑ 3 ❑ 31/2
7 Weld County Addendum to the CWS-7A
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maintenance
Rate A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
Ott
$23.01
1 112 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
tsrel $29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
yo
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.62 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$ $( Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency "44 $30.25 day/$920 month(Includes Respite)
Rate
tieg
Effective 7/1/2008
8 Weld County Addendum to the CWS-7/
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerl the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
ELa\ �
By: ,a , �.. n it ; Jau�. (11i )112O,r/p/c-
De ty Clerk tot ( :o.r 43v�� Chair gnature //
t AUG 1 0 2011
Approval as to Substance: � ' qt��, PROVIDER
WELD COUNTY DEPARTMENT Gomez, Oswald and Christina
OF HUMAN SERVICES 7226 Matheson Dr.
Fort Collins, CO 80525
By. By.
Di•ector
By.
O7Oi/- a/2c
9 Weld County Addendum to the CWS-7A
LWS-/A(KIU-IU/993
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND 2911 JUL I$
FOSTER CARE FACILITY AGREEMENT fin 10 rn
1. THIS CONTRACT AND AGREEMENT, made this date, 74/i by and between
the Board of Weld County Commissioners, sitting as the Board of ocial Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Gomez, Oswald and Christina, Provider ID# 1588508, 7226 Matheson Dr., Fort Collins, CO
80525, hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2011 and continue in force until
June 30, 2012 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24-hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
(-WS-/A(KIU-IU/99)
1?. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out-of-home provider.
2
I:WS-/A(KIU-IU/99)
4., To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
opoinasni‘p SERVICES, ON BEHALF OF THE WELD
i- I £ COUNTY DEPARTMENT OF HUMAN
®` SERVICES
`
BY: . • A I. ! *Patilt %mei. B ' J /
D- 'uty Clerk to the silt:' '.' AUG G 2011
. Chair Sign ture
Approval as to Substance: „. p'•
en r PROVIDER
WELD COUNTY DEPARTMENT Gomez, Oswald and Christina
OF HUMAN SERVICES 7226 Matheson Dr.
Fort Collins, CO 80525
By: 6tthP4
By:0 O'
C� -By:
3
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