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Home My WebLink About20112243 MEMORANDUM 1 8 6 1 - 2 0 1 1 DATE: August 9, 2011 TO: Barbara Kirkmeyer, Chair, Board of County Commssio ers FROM: Judy A. Griego, Director, Human Servi epadmen WELD,COUNTY V RE: Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements and the Weld County Addendums to the Agreements between the Weld County Department of Human Services and Various Providers for Consent Agenda Enclosed for Board approval are Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements and the Weld County Addendums to the Agreements between the Department and Various Providers. These Agreements can be placed on the Consent Agenda. The major provisions for these Agreements are as follows: No. Provider/Term Facility Type/Location 1 Hoeft, Kimberly Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 2 Hoel, Elizabeth Foster Home July 1, 2011 —June 30, 2012 Dacono, Colorado 3 Jude, Yvonne Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 4 Kinney, Frederick and Margaret Foster Home July 1, 2011 —June 30, 2012 Eaton, Colorado 5 Kniss, Kevin and Kelly Foster Home July 1, 2011 —June 30, 2012 Thornton, Colorado 6 Maronek, Dennis and Patricia Foster Home July 1, 2011 —June 30, 2012 Firestone, Colorado 7 Martinez, Andrew and Jeanna Foster Home July 1, 2011 —June 30, 2012 Evans, Colorado 8 McCreery, James and Tammy Foster Home July 1, 2011 —June 30, 2012 Eaton, Colorado 9 McGee, Donna Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 10 McKeown, Anthony and Jessicca Foster Home July 1, 2011 —June 30, 2012 Platteville, Colorado 11 Means, Nathan and Lisa Foster Home July 1, 2011 —June 30, 2012 / Greeley, Colorado #1,e 7v6pog -/9 2011-2243 12 Mellmen, Jeffrey and Letha Foster Home July 1, 2011 —June 30, 2012 Eaton, Colorado 13 Mena, David and Marie Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 14 Middleton, Brian and Deborah Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 15 Moore, Earl and Patricia Foster Home July 1, 2011 —June 30, 2012 Lochbuie, Colorado 16 Parker, Brian and Beryldell Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 17 Pierce, Kris and Larry Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 18 Pluma, Mike and Annette Foster Home July 1, 2011 —June 30, 2012 Kersey, Colorado 19 Ramos, Julian Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 20 Redding, Christopher and Sonja Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 21 Reussow, Robert and Tracy Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 22 Ritter, Thomas and Deborah Foster Home July 1, 2011 —June 30, 2012 Firestone, Colorado 23 Roderick, Douglas and Kelli Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 24 Rogers, Jeffrey and Tami Foster Home July 1, 2011 —June 30, 2012 Firestone, Colorado 25 Rush, Phillip and Shannon Foster Home July 1, 2011 —June 30, 2012 Aurora, Colorado 26 Schnitzer, Daniel and Daniela Foster Home July 1, 2011 —June 30, 2012 Aurora, Colorado 27 Serna, Leo and Carol Foster Home July 1, 2011 —June 30, 2012 Windsor, Colorado 28 Sevestre, Lewis and Maureen Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 29 Shindle, Danny and Andrea Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 30 Skeldum, William Foster Home July 1, 2011 —June 30, 2012 Johnstown, Colorado 31 Spahr, Mary Ellen Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 32 Steele, Dana and Cassandra Foster Home July 1, 2011 —June 30, 2012 Johnstown, Colorado 33 Steitz, Daniel and Natalie Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 34 Van Den Elzen, Dawn Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 35 Vincent, Jessica and Ryan Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 36 Wade, Michale and Jodyne Foster Home July 1, 2011 —June 30, 2012 Windsor, Colorado 37 Walker, Kurt and Jennifer Foster Home July 1, 2011 —June 30, 2012 Windsor, Colorado 38 White, Richard and Melissa Foster Home July 1, 2011 —June 30, 2012 Greeley, Colorado 39 Willert, Melody D. and Foster Home Lee, Kimberly LaSalle, Colorado July 1, 2011 —June 30, 2012 40 Wyatt, James and Jill Foster Home July I, 2011 —June 30, 2012 Eaton, Colorado If you have questions, please give me a call at extension 6510. I,WS-/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, 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, Hoeft, Kimberly, Provider ID# 1603004, 5551 W 29th Street, Unit 712, 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 WJ-/A(KIU-I W99) • 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 (-WS-/A(KIU-1U/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 is La SERVICES, ON BEHALF OF THE WELD `� COUNTY DEPARTMENT OF HUMAN � SERVICES Dep , Cler to the rib �� r `�$ Chair Sign tureAUG 1 72011 "OuApproval as to Substance: / PROVIDER WELD COUNTY DEPARTMENT Hoeft, Kimberly OF HUMAN SERVICES 5551 W 29th Street, Unit 712 Greeley, CO 80634 By: By: 7k 6 r/ ±(2 A i �!��c Cal iCior By: 3 ax//-as cc3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Hoeft, Kimberly 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 JAM, 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#1603004. 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//- ?73 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? ❑ Basic Maint.)No participation required ❑1)Once a month 011/2)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? O Basic Maint.)No educational requirements 01)Less than a ''/z hour per day 011/2) 1/2 hour a day 02) I hour a day 02 ''/) 1'/-2 hours per day 03)2'/r3 hours per day ❑3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 14 hours per week ❑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 ❑2'/z) 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. 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. ❑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%)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? 00)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (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 8 81 to this child. 4 .;' Y--j,- # 1 R ":•:).;# .;• 1 . ,4r,iva Y ` q ar .� - asd,T A.,>xh rah t is 3� ...bRy z� tri i'+am✓;e n^ .e. .r . .. vvd:'�L°v ":.3}`.re�5Y ceh._.a rn�. A. . y .. +,..x....x ^"Yi8kR"9 i.$ . .... n1 Aggression/Cruelty to Animals ❑ O O ❑ ❑ O O Verbal or Physical Threatening ❑ 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ O O O O O O Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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/intensit of conditions which create the need for services that a..l to this child. wit Inappropriate Sexual Behavior 0 0 0 0 ❑ 0 0 Disruptive Behavior ❑ 0 ❑ ❑ ❑ 0 0 Delinquent Behavior ❑ 0 0 0 0 0 ❑ Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ 0 0 ❑ 0 0 ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 ❑ 0 0 Eating Problems ❑ ❑ ❑ ❑ 0 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ ❑ ❑ ❑ 0 0 0 Education ❑ ❑ ❑ ❑ ❑ ❑ 0 Involvement with Child's Family ❑ ❑ 0 0 ❑ 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 2'h ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS-7A • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 3�zvP any�`� S�x ��s8 `� �m3 ��';•••₹��".z�`d 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) $23.01 1 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) fi Nfti $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) Fowl $29.59 21/2 4.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 4.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 4.66 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 La Effective 7/1/2008 8 Weld County Addendum to the CWS-7A • ' 'IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the WELD COUNTY BOARD OF SOCIAL r �* SERVICES, ON BEHALF OF THE WELD a`� COUNTY DEPARTMENT OF HUMAN s, -SERVICES 861 Q 2 By: /..�i/ii�t (�I �.f�.'�/.'�'i!/ �� B Deputy r erk to the Bo ' a (�' � Chair Si ature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hoeft, Kimberly OF HUMAN SERVICES 5551 W 29th Street, Unit 712 Greeley, CO 80634 ^ By: By: f(.-6-e Lis, —hi. Jl�'�'_ _[ Dire for 1 By: 9 Weld County Addendum to the CWS-7A LWS-FA(KIU-IW99) 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, Hoel, Elizabeth, Provider ID# 1560688, 728 Glen Ayre St, Dacono, CO 80514, 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/A wad= 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(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 B.=t7 ♦ WELD COUNTY BOARD OF SOCIAL fi �4E.1�aSERVICES, ON BEHALF OF THE WELD OUNTY DEPARTMENT OF HUMAN 1/42 =� RVICES / 1b61 O 7, By: i% /,/. ��. _�i�i ��y: "tic 4_ 6(,/l tit.'L Deput l erk to the Boar. �U cOtt • Chair Sig ature 1 Approval as to Substance: PROVIDER pa 72011 WELD COUNTY DEPARTMENT Hoel, Elizabeth OF HUMAN SERVICES 728 Glen Ayre St Dacono, CO 80514 By: By: . ,Lc. '',, 1 . D ector By &.1 6. i} 3 C2 //-cit7 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the"Agreement") between Hoel, Elizabeth 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 day of i� , 2011, are added to the referenced Agreement. Except as modified hereby, all terms of th�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#1560688. 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. aaii-a'a y 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 01)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'/:)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? al Basic 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 ❑l) Less than a '/,hour per day 01%) 1/2 hour a day 02) I hour a day 02 'A) 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? ® 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 ❑1'/:)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) I I 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) IliBasic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 011/4)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) ❑I)Less than 4 hours per month 2)4-8 hours per month 03)9-12 hours per month 5 Weld County Addendum to the CWS-7ft (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. °'�' a.1ui:'4.�'ait. 3:;','. . '.. . ... :'.... . �:'.: e .-' �.�k.' r. '" � � a` Aggression/Cruelty to Animals N ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ O O O O O // Destructive of Property/Fire Setting O O ❑ O ❑ O O Stealing / ❑ ❑ ❑ N O O / ❑ O Self-injurious Behavior \ O O ❑ ❑ O O Substance Abuse ❑ ❑ ❑ ❑ \\ ❑ O O Presence of Psychiatric Symptoms/Conditions O O O ❑ O O Enuresis/Encopresis \ ❑ O O O \ ❑ ❑ Runaway / \\ O O O O ❑ \ ❑/971 Sexual Offenses ❑ ❑ ❑ 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 a..I to this child 'ay' c shy a a Pi# 2. Y #rl tss�,t ' t ,[ , ') `? ,i,rc ,' o- s :gyp' -7 y_ + r , dy 4 t . t • + r , maa^�+� '. ..i ,,. ti H�';N4 3 .,e'��.a. P .tea,. ;+' a , � 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 ❑ O O O O O O Eating Problems ❑ O O O O O O Boundary Issues ❑ O O O ❑ O ❑ Requires Night Care ❑ O O O O O O Education ❑ O O O O O ❑ Involvement with Child's 110(4; feU Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1% ❑ 2 ❑ 2'h ❑ 3 ❑ 3'/z 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) $19.73 1 +$.66 Respite Care t. Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) ae. $26.30 2 +$.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) $36.16 3 1/2 +$.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 Rate _ $30.25 day/$920 month(Includes Respite) 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 WELD Si La COUNTY DEPARTMENT OF HUMAN SERVICES 361r / 1/42 By: B • `' GEC L-t :e'<. t, Deputy erk to the Chair S' nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hoel, Elizabeth OF HUMAN SERVICES 728 Glen Ayre St Dacono, CO 80514 _Are By: BY: C)��iy�) /`}t /S" I� Dir ctor l By: lkfui[. aeWaX 9 Weld County Addendum to the CWS-7A LWJ-/A (KIU-IU/99) • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 811 19 Pi pot cu 1. THIS CONTRACT AND AGREEMENT, made this date, �i 1 a I Ifi(! ay ana 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, Jude, Yvonne, Provider ID# 1585656, 2406 14th Ave, 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. 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 • LWN-/A trciu-iunvf ,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. I ATTEST: Weld County Clerk to the,.,` Is Edo WEELDI COUNTY BBOARDF OFF SOHECIAL OUNTY DEPARTMENT OF HUMAN LD 361 �.�ERVICES By: �,� ii . �i� I9�i ��% � B : �`ii tbatte'L_ Deput lerk"to the Board "♦r!1 #' Chair Signa re Approval as to Substance: PROVIDER AUG 1 7 2011 WELD COUNTY DEPARTMENT Jude, Yvonne OF HUMAN SERVICES 2406 14th Ave /� Greeley, CO 80631 By: A a, l// VWv B o� irector 3 air--aa3 WELD COUNTY ADDENDUM ?QII JUL 19 To that certain Individual Provider Contract for Purpose of Foster Care y'7 9 $y Services and Foster Care Facility Agreement (the "Agreement") between Jude, Yvonne 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 day of tJ 2011, are added to the referenced Agreement. Except as modified hereby, all terms of the 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#1585656. 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 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 ❑I'/z)2 round trips a week ❑2)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week ❑3%)7 round trips or more 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 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 01%)1/2 hour a day 02) 1 hour a day 02 %) I'/:-2 hours per day 03)2'h-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? O Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week 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%) 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.) ❑I)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) 01)Less than 4 hours per month ❑2)4-8 hours per month 03)9-12 hours per month 5 Weld County Addendum to the CWS-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 II to this child. T ^q:-;, .- f to Aggression/Cruelty to Animals O O O O O O O Verbal or Physical Threatening ❑ 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 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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/intensit of conditions which create the need for services that a..I to this child. r ;' s Inappropriate Sexual O O O O O O O Behavior Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ O O O O O Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family O ❑ O O O O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1''A ❑ 2 ❑ 2'h ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7/) • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE • "S S U hlY `. 4 3 4H V • ..,d•AkS �R�.Wu•mm�x��i Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance : Rate <m Age 15-21...$19.27/day ($586/month) rt +Respite Care$.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) j'• $26.30 2 +$.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 r.. 4.66 Respite Care Total Rate=($33.54day/$1020 month) n7� $36.16 3 1/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down ($ +$ Respite Care Au, 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 oard WELD COUNTY BOARD OF SOCIAL Slid SERVICES, ON BEHALF OF THE WELD a % COUNTY DEPARTMENT OF HUMAN SERVICES �S1/42 BY By, 4.44L /LA Deputy 'lerk to the aly�+ir�� Chair Si nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Jude, Yvonne OF HUMAN SERVICES 2406 14th Ave Greeley, CO 80631 By: By; ii ctor By: 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-1U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7////f by and between the Board of Weld County Commissioners, sitting as the Board o Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Kinney, Frederick and Margaret, Provider ID# 1547583, 640 E 3rd St, Eaton, CO 80615, 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 CWS-IA(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 lerk to La WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD J•/ • ' COUNTY DEPARTMENT OF HUMAN / m t k al, ' SERVICES By:��ii,/ Y B4'cLt,C1[ Deputy Perk o the Bo'%Z__4 y► Chair Sig ature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Kinney, Frederick and Margaret OF HUMAN SERVICES 640 E 3rd St Eaton, CO 80615 By. By. a irec By: 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Kinney, Frederick and Margaret 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 tie j , 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#1547583. 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. ,2d// 47t3 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 01)One round trip a week ❑l'/)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 ❑1)Once a month 01%)Two times month 02)Three times a month 02%)Once a week 03)Two times a week 03%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a ''/z hour per day 011/2)'A hour a day ❑2) 1 hour a day 02 %) I'/-2 hours per day 03)2'/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 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 ❑1'/z)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.) ❑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 ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..l to this child. �& +* " 7 r . % yfa k'- ax _:,,,+::::-..( ��3'}a r- pc. ``s w ° f. - wtt w tx ffi` .. "' yews a++ ,sd[t,bx._, at..,„,, ,, - :r r g-. -..�S,,'.,, ar .�. ... ... '. : ,. .. ,. e t .c a r9�6dr .' _m.T Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 ❑ 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ 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 a..1 to this child k vd.l 4 e x hI f Y in'+ 77 h. 8 L*S.{,. s. r via, ;l 1.4 ih t gig: =alkiallif" °b i. - ..r . t.---w 'P:: . .Mr,, 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••, 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 O Boundary Issues ❑ ❑ ❑ ❑ ❑ O O Requires Night Care ❑ O 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 ❑ 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•6 } t S. f •a . • ,t,� `sue "`t: ' f -.._'�- t1� o ''" s n ,n sia' ws acv a� a4 :1 rtP c 3 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) f !"")+) $23.01 1 1/2 +$.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 10.4 4.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) svzi $36.16 3 1/2 4.66 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 g 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 • y , S La`� SERVICES COUNTY SE ` 4 tut 1/;l7•. �' ByY' i lW-GI-- Deputy/ erk to the 4k`k� B Chair gnature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Kinney, Frederick and Margaret OF HUMAN SERVICES 640 E 3rd St Eaton, CO 80615 By: By: i ector By: 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-1U/99J ` INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, I, -16/Q I I / (j by and between the Board of Weld County Commissioners, sitting as the Iard1Social ervices, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Kniss, Kevin and Kelly, Provider ID# 1524303, 13089 Marion Dr., Thornton, CO 80241-1936, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 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,WJ-/H(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 CWS-/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 SERVICES, ON BEHALF OF THE WELD : � COUNTY DEPARTMENT OF HUMAN SERVICES By. e ti-ii, _. A,<f'l (fr 2 Deput lerk tot .B• Chair Sign lure ° ��I� Approval as to Substance: � V� � PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT �►� Kniss, Kevin and Kelly OF HUMAN SERVICES 13089 Marion Dr. ^^ II Thornton, CO10:241-1936 BY: L AA,i JO ) BY:. . ' 'Q� .cfl �irector G� By: 3 a0//-0U*/.3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Kniss, Kevin and Kelly and the Weld County Department of Human Services for the period from July 1, 2011 through June 30, 2012. The following provisions, made this It- day of �l i , 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#1524303. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. 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 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 d'/z)2 round trips a week O2)3-4 round trips a week. ❑2%z)5 round trips a week O3)6 round trips a week ❑3%z)7 round trips or more 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 ■I%)Two times month ❑2)Three times a month O2%)Once a week ('.'i't 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? O Basic Maint.)No educational requirements ❑1)Less than a '/z hour per day ❑i'/o z hour a day g2) 1 hour a day O2 '/z) I'%-2 hours per day O3)2'/z-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 ❑l)Less than 5 hours per week ❑1%z)5 to 7 hours per week i2)8 to 10 hours per week O2%) 11 to 14 hours per week 3)Constant basis during awake hours ❑3'/z)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week VI)3 to 4 hours per week ❑1%)5 to 7 hours per week O2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)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.) ❑ ))Face-to-face contact one time per month with child and minimal crisis intervention. MA 11%) Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T I. How often are therapy services needed to address child's individual needs per NBC assessment? V)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month )4-8 hours per month O3)9-12 hours per month 5 Weld County Addendum to the CWS-7/ (Exhibit B)(Example only do not complete) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that al.I to this:child. � ��t Yf z$ 4 a, .u{fiR�v, �. - r �. q t itk ya a s S Aggression/Cruelty to ,..�( Animals N O O O O O O Verbal or Physical Threatening O O O O O O Destructive of Property/Fire Setting O O Ili O O O O Stealing ❑ N O O O O O Self-injurious Behavior ❑ d ❑ ❑ ❑ ❑ ❑ Substance Abuse Bi ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric �/ --" Ts D Symptoms/Conditions O O O L� ❑ ❑ Enuresis/Encopresis Cr O O O O O O Runaway ❑ f/ ❑ ❑ ❑ ❑ ❑ Sexual Offenses 4O,... cuf.r-, due d ❑ ❑ O O O ❑ pas* htsiv , r-taw cans-it " (Inc -of-s ` (_Ap2rvis on • Weld County Addendum to the CWS-7P (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..1 to this child. ti ewe Inappropriate Sexual �( Ste- peepee $out S Behavior 0 0 KI 0 0 0 O C,OVYmeAr f, Disruptive Behavior ❑ ❑ ❑ ❑ M 0 0 Delinquent Behavior ❑ Id ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ d ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ ' ❑ 0 0 0 0 please complete the Medically fragile NBC) Emancipation F ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ d ❑ 0 ❑ 0 0 Boundary Issues ❑ ❑ ❑ 537 ❑ ❑ ❑ er Requires Night Care Mon+2>YS� ❑ 51 ElV'ltd❑ ❑ ❑ ❑ 00 V P ria)n o.lerl- wYtevt Owe is toD Education lDi.te it' ke,lau1ors4 attat Eli(Si swbool24 a-4- o atone- — recr trra Involvement with Child's / b Family ❑ I ❑ El ❑ ❑ g,, Ihrl�{ ��l mo '`t hr/ al /3mo CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/ ❑ 2 ❑ 2'h ❑ 3 ❑ 31/2 7 Weld County Addendum to the CWS-7/ (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE I t. 1SQ $ Age 0-10...$16.32/day ($496/month) Ra County Basle Age 11-14...$18.O5/day ($549/month) Maintenance `ifC"- Rate Age 15-21...$19.27/day ($586lmonth) xi33 +Respite Care$66/day ($20/month) $$6196/d73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) yyY# $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) v $29.59 2 1/2 +$.66 Respite Care *id Total Rate=($30.25 day/$920 month) =Gtk `.Ls4r= $32.88 3 +$.66 RespRe Care �` Total Rate=($33.54day/$1020 month) $36.16 3 112 +$.66 Respite Care Total Rate:$ ($36.82 day/$7,120 month) .3r. :un $39.45 TRCCF Drop Down ' +$.66 Respite Care Total Rate=($40.11 day/$1220 month) n r) x AssessmentlEmergency Rate ', $30.25 day/$920 month(Includes Respite) Effective 7/1/2008 CWS-7P 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 to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD t. E La COUNTY DEPARTMENT OF HUMAN `,- •p =, SERVICES 61 t! 3 By ByF )� Ultll' c Deputy Ir erk to the ?c< ci 7c Chair � 14�f/ Signature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Kniss, Kevin and Kelly OF HUMAN SERVICES 13089 Marion Dr. Thornton, CO 80241-1936 By: By: (JpjectorUU /J _ By:r2fy i% 9 Weld County Addendum to the CWS-7A I,WJ-/H(KIU-IU/99) • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7/44 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, Maronek, Dennis and Patricia, Provider ID# 1520627,4860 Eagle Crest Blvd, 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 HuAii Services. 6. To keep confidential the information shared about the child and his/her famil rte" 7. Not to accept money from parents or guardians. �a 8. Not to make any independent agreement with parents or guardians. Cu 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 0)2c//-a2a 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 Fines 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 fed6 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 majtained for each child in accordance with Volume 7 requirements. co 21. To maintain medical, dental and educational records for each child/youth andysupply updated information to the County Department. —3 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-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 accord made thereof on a case by case basis. r� 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. —C ATTEST: Weld County Clerk to the Boar WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD �� 6 Las COUNTY DEPARTMENT OF HUMAN f y � :• SERVICES By: I �i/L[ �aC/9J /a�r/ ��By. l C lCi \— Deputy lerk o the Bi4'� j � ! Chair Sign ure Approval as to Substance: i�„ j�� PROVIDER AUG 1 7 2011 WELD COUNTY DEPARTMENT Maronek, Dennis and Patricia OF HUMAN SERVICES 4860 Eagle Crest Blvd Firestone, CO 80504 �y By: By: f ; a c 111 S '1YJti Dir ctor ,f n n� By: ik .e4t/lua /a (t.y4' 4 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the"Agreement") between Maronek,Dennis and Patricia 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 , 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#1520627. 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 forashild's temporary absence from a facility, including hospitalization. Bed hold requesWsinust have prior written authorization from the Department Administrator before paAnent will be release to Provider. CA) 4. Any additional costs for specialized services, which may include but are not ited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be a>�orized, in writing by the Department Administrator, prior to the service being performed, Any payment for specialized services not authorized in writing may be denied. . 1 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. c9&i/4{.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; ti 0 B. Deny payment or recover reimbursement for those services or delibt'.tables which have not been performed and which due to circumstances caused he Provider cannot be performed or if performed would be of no value to the an Services. Denial of the amount of payment shall be reasonably related to the-amount of work or deliverables lost to Human Services; .-t, ra C. Recover from the Provider any incorrect payment due to omissiort,srror, fraud, and/or defalcation by deducting from subsequent payments under is Agreement or other agreements between Human Services and the Provider, oily 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 repiewed on a monthly basis and signed off by child's caseworker and/or the provider's Focter Care Coordinator. ca -n 10. Maintain/update medication logs on a daily basis, if child is taking medication w 11. Maintain behavior observation notes as required by the level of care assessed Sr 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) C- c r- -17 CA) -a 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 Di 1/2)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 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 %x) l'/s-2 hours per day 03)2'/s-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 ❑1%)5 to 7 hours per week 02) 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 ❑1)3 to 4 hours per week 01%)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 03%)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) .". L ['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. r— (i.e.mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. w 01%)Face-to-face contact one time per month with child and occasional crisis intervention. 'T3 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. C. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensiwt 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/intensi of conditions which create the need for services that a..1 to this child. x ,i AS ati Aggression/Cruelty to Animals O 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 M Substance Abuse .,. L 1-- ,, Presence of Psychiatric Symptoms/Conditions ❑ O O O O O O z C) Enuresis/Encopresis y ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ O O O O O O Sexual Offenses ❑ ❑ 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/intensit of conditions which create the need for services that a.91 to this child. }, 3k h A , C i +}S"} 'Tr1 t bi re m. ,. . ... .. .. .•... x r. . ,.ea. r--'..:I's. . .. .. ..w . .„. 'x�„,sr.,.,'s`�� .�r.� . . Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation L Eating Problems r- 0 ❑ ❑ 0 0 0 0 t V Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ " . .,c Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1% ❑ 2 ❑ 2% ❑ 3 ❑ 3'h 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE lmg 4s _ t/ 4 s i7 t* di 9� siw�d a xh wtt� t is se Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance 1e'ie Rate "'+° Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care .'_4 Total Rate= ($20.39 day/$620 month) $23.01 1 112 e: +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 t +$.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 2,'Cs Total Rate=($33.54day/$1020 month) $36.16 3 1/2 +166 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/$920 month(Includes Respite) Rate Z, Effective 7/1/206@ Cu V 8 Weld County Addendum to the CWS-7/ IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD s La`s NTYDEPARTMENT OF HUMAN SERVICES :�� il !mil .��✓ 'f'� �J �By. B cc4CC� l Ck Deputy erk to the N �� Chair gnature 1'.Qy AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Maronek, Dennis and Patricia OF HUMAN SERVICES 4860 Eagle Crest Blvd Firestone,too CO 80504 0By: By: F( u2r.�, 1416..4„0-a-R` rector c I, BY: IS Giwre%7 h1 0 C r-- co co -c 070//-aag 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT an JUL 13 fin 9 S$ 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, Martinez, Andrew and Jeanna, Provider ID# 1585195,4404 Monte Cimone St, 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 L W J-/A (K 1U-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 WJ-/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 yt a /S WELD COUNTY BOARD OF SOCIAL Q°u�`` SERVICES, ON BEHALF OF THE WELD ►,COUNTY DEPARTMENT OF HUMAN ,. .aw �• .ERVICES 1961 It "Os -, \a'\\ Deputy lerk to the Boa `�`' ('1 D Chair S' nature / Approval as to Substance: PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Martinez, Andrew and Jeanna OF HUMAN SERVICES 4404 Monte Cimone St n� Eva s, CO 0620 By: / (/'�� r}f�� By: hector By: 3 do//-aO? WELD COUNTY ADDENDUM X911 JUL To that certain Individual Provider Contract for Purpose of Foster L 2 tlPl re 9 55 Services and Foster Care Facility Agreement (the "Agreement") between Martinez, Andrew and Jeanna 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 t) ,2011, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement 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#1585195. 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. 07&/-cd9,3 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 ❑1'/i)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? O Basic Maint.)No participation required DI)Once a month ❑1'/)Two times month 02)Three times a month 02%)Once a week 03)Two times a week ❑3'/)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements DI)Less than a %3 hour per day 011/2)1/2 hour a day ❑2) 1 hour a day 02 %S) 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 ❑1'/)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3%:)Nighttime hours 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 ❑1'%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/:) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%x)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) DI) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/)Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑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 behavior/intensit of conditions which create the need for services that a..I to this child. Aggression/Cruelty to Animals ❑ 0 0 0 0 0 0 Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ 0 0 0 0 Runaway ❑ ❑ ❑ 0 0 0 0 Sexual Offenses ❑ ❑ ❑ 0 0 0 0 6 Weld County Addendum to the CWS-7P (Example only do not complete) (Exhibit B) • WELD COUNTY OHS 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. mss"N xx: - .. rya i b ,;.s ' s to tra sail ' �,.. . mom.. . , . . , . . ., „�.at,..��.ee '!..•.:.:..�._,. . . .. ..:.4 yS: +`�c.:#asu:' s$;aa%. xv Inappropriate Sexual Behavior ❑ O O O O O O Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe', ❑ O ❑ O O O O please complete the Medically fragile NBC) Emancipation ❑ O O O O O O Eating Problems ❑ ❑ ❑ ❑ ❑ O O 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'/z ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7P (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 1 ieh r '3.x z ) �• fi t. . t r § . . sy 5 a aeuW3r . Age 0-10...$16.32/day ($496/month) County Basic i Age 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 7 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) z .. $23.01 1 1/2 ={`l* +$.66 Respite Care Total Rate=($23.67 day/$720 month) 51E(� $26.30 2 +$.66 Respite Care 14 Total Rate=($26.96 day/$820 month) $29.59 21/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 _ 4.66 Respite Care Total Rate=($33.54day/$1020 month) iA $36.16 3 1/2 4.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down :,‘7,q +$.66 Respite Care Total Rate=($40.11 day/$1220 month) p t rrx 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 s(L,a% COUNTY DEPARTMENT OF HUMAN SERVICES 1/42ABy: ' �' i. L�J%IiI � j By t__ Deputy lerk to the ' � � � � Chair Si ature '� ,�i► AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Martinez, Andrew and Jeanna OF HUMAN SERVICES 4404 Monte Cimone St Evans, O 80620 B Y By: iit Dir ctor By: 9 Weld County Addendum to the CWS-7A I.WJ-/A (KIU-1U/99) t • 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, McCreery, James and Tammy, Provider ID#40215, 120 Maple Ave, Eaton, CO 80615, 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©/i cVa UWS-/A (KIU-1U/99) ;I 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 LWS-/A((10-10/99) ,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 th` .;t" L�/j�� WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN l' �ZA�g -1-ERVICES 561• 1K • By: CcC Depu lerk to the Boar Chair Chair Sig ature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT McCreery, James and Tammy OF HUMAN SERVICES 120 Maple Ave Eaton, CO 80615 By: By 7 rec or By: 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between McCreery,James and Tammy 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 , 2011, are added to the referenced Agreement. Except as modified hereby, all term 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#40215. 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 ❑I)One round trip a week DI'/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 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 02)Three times a month ❑2%)Once a week 03)Two times a week O 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 '/z 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 activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/) 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 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. O 1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two timesper 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/intensi of conditions which create the need for services that a''I to this child. F"§,£#LAS - -q t. ay. n'; 4'2:4 % 15:^1.4.1H... r e a '': r ':''::4:-:414 til‘attatatiti.c,, .n.,,. .. ,. ,.,.:,: . ..r."!kee`=. axa. . .. (. „o�ysa.xu: :n.Erx).:at' ., 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 Presence of Psychiatric Symptoms/Conditions O O ❑ O O O O Enuresis/Encopresis ❑ O O O O O O Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ 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/intensit of conditions which create the need for services that a..1 to this child. u� Ra d 1 i t . 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 O O O O O please complete the Medically fragile NBC) Emancipation ❑ O O O O O O Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ O ❑ O O O Requires Night Care ❑ ❑ ❑ ❑ 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) El0 ❑1 ❑ P/2 ❑ 2 El 2'/z ❑ 3 ❑ 3'h 7 Weld County Addendum to the CWS-7/ . (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE i F u � tt 1 LS 4 9S�F3 s � ? k,47. a .P1 , w t i Y i� t 3 ,. • �i �i E 4 q'rya + R Y 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 ($586/month) ki$' +Respite Care$.66/day ($20/month) $19.73 1 ' ! +$.66 Respite Care Total Rate= ($20.39 day/$620 month) t $23.01 1 1/2 n '. +$.66 Respite Care =•7.. Total Rate=($23.67 day/$720 month) ft�s $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 4.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 h +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 ;fr $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-7i - • ' IN WITNESS WHEREOF,the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the = • WELD COUNTY BOARD OF SOCIAL 4Sada SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES 1/42 .861 By: A B : "-ft 1 ,<,//7(Lit „. Deputy perk to the Bode I r Chair ignature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT McCreery, James and Tammy OF HUMAN SERVICES 120 Maple Ave Eaton, CO 80615 By. Bye '. � / f 'rector By: „aO-4 S2W%.0749e 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-IU/99) • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, r' ' J t 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, McGee, Donna, Provider ID#1539853, 1649 31st Ave, 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:WS-/A (KIU-IU/9V) 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 WELD COUNTY BOARD OF SOCIAL 3 fa La`s` SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Xso (J %q By: ,/i// ' rl.. By: Deputy! erk to the B ' `}U TOIC Chair gnature Approval as to Substance: PROVIDER AUG 1 !2011 WELD COUNTY DEPARTMENT McGee, Donna OF HUMAN SERVICES 1649 31st Ave Greeley, CO 80634 c�� j By: adi By: U/!/Vl� 0 U Irector� r By: 3 • WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between McGee, Donna and the Weld County Department of Human Services for the period from July 1, 2011 through June 30, 2012. The following provisions, made this b day of , 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#1539853. 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 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 ❑l)Once a month 01%)Two times month 02)Three times a month ❑2'/)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 ❑1)Less than a''/I hour per day 01%) 1/2 hour a day 02) I hour a day 02 '/x) I'''A-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 ❑2) 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. ❑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) 01)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/intensi of conditions which create the need for services that a..l to this child. Aggression/Cruelty to Animals O O O O O O O Verbal or Physical Threatening ❑ O O O O O O Destructive of Property/Fire Setting O O O O O O O Stealing ❑ ❑ ❑ ❑ ❑ O O Self-injurious Behavior ❑ ❑ O O O O ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions O O O O O O O Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ O O O Sexual Offenses O O O O 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/intensit of conditions which create the need for services that a..1 to this child. mss: I .: t. 5y ;',, i y 0 yN_ -. .... _.%:°,ttette'�'i k . . .: . w �aaP.. e..: .., . , tdP":.�f+.e..'�"4 ::. .. ... 1. . . 1�.�` ��.s4'S.• � f Inappropriate Sexual Behavior ❑ ❑ O O O O 0 Disruptive Behavior ❑ O 0 O O O O Delinquent Behavior ❑ O O O O O O Depressive-like Behavior ❑ O 0 El 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ O O ❑ 0 0 0 Eating Problems ❑ O O O 0 0 O Boundary Issues ❑ O O O O O O Requires Night Care ❑ O O O O O O Education ❑ 0 0 O O 0 0 Involvement with Child's Family 0 0 0 O 0 0 O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 9 1''A ❑ 2 ❑ 2'/z 9 3 ❑ 3'/z 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) $19.73 1 „, +$.66 Respite Care 3 Total Rate= ($20.39 day/$620 month) $23.01 1 112 +$,66 Respite Care ''a' Total Rate=($23.67 day/$720 month) } $26.30 2 +$.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 ti Total Rate=($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 t $39.45 TRCCF Drop Down F +$.66 Respite Care Total Rate=($40.11 day/$1220 month) ua`a` Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 $ 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 V , BEHL O T �-d.�� -' COSERUNTYICES DEPARTONMAENTF OFF HHEUMANWELD SERVICES By ��/ //. n �i/I i f% '1 By /74 Deputy ti Deputy *i erk to the 1:. CO U / Chair i nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT McGee, Donna OF HUMAN SERVICES 1649 31st Ave Greeley, CO 80634 By: By: roz/fria ,,a D rector By: &C//-12229g 9 Weld County Addendum to the CWS-7A Iwo-/A(KIU-iwvv) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, ko `� y a dI� gen the Board of Weld County Commissioners, sitting as the Board of So 'SeWfcJs`or Ilff the Weld County Department of Human Services, hereinafter called "County Department" and, McKeown, Anthony and Jessicca, Provider ID# 1556968, 722 Goodrich Ct, Platteville, CO 80651, 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 c20//-e“k3 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 Bo WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD �°Q'a ` COUNTY DEPARTMENT OF HUMAN -, SERVICES Fi ry. • Deput Clerk to the B '6 nl"n'G�. Chair S nature AU 72011 Approval as to Substance: °�►.:vi� PROVIDER WELD COUNTY DEPARTMENT McKeown, Anthony and Jessicca OF HUMAN SERVICES 722 Goodrich Ct Platteville, CO 80651 By: By: rector By: 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between McKeown, Anthony and Jessicca and the Weld County Department of Human Services for the period from July 1, 2011 through June 30,2012. The following provisions, made this V4 day of Q A , 2011, are added to the referenced Agreement. Except as modified hereby, all terms of he A reement 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#1556968. 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. DR)/7 aa93 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 aint.)Less than one round trip a week DI)One round trip a week ❑1'%)2 round trips a week ,g2)3-4 r nd trips a week. 02%)5 round trips a week 03)6 round trips a week ❑3%:) 7 rou trips or more Comments: P 2. How often is the fo er care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No p' icipation required DI)Once a month ❑1%,)Two times month _g2)Three times a month 02%)Once a week 03)Two times a week 03%)Three times a week more Comments: \` l - P 3. How much time is the provider equired to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requt ments ❑l) Less than a''/I hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 'A) I'/:-2 hours per day ,g3)`f'h-3 hours per day ❑3%)More that 3 hours per day Comments: P 4. How often does the child require special and ex nsive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑I) ss than 5 hours per week ❑1%)5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 1 to 14 hours per week j'3SConstant basis during awake hours 03%)Nig ime hours Comments: P 5. How much time is the provider required to assist the child because o ' pairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ip 3 to 4 hours per week ❑1%)5 to 7 hours per week ❑2) 8 to 10 hours per week /) 11 to 15 hours per we ❑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. /21%)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%)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 tha ne 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? -FS)Not needed or provided by another source(i.e. Medicaid) DI)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (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. �' F "549^ SAN `S "4 f �%. k � t iv L ,; .�. � . .. a.R.` ./1:221;".,::�µsa..z .ndf#YT:°PN�.a . Aggression/Cruelty to Animals ,.....El 0 ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 0 ❑ .i>"--- 0 0 0 Destructive of Property/Piro-Setting' 0 0❑ 0 0 ,— 0 0 Stealing ❑ ,J;r— . 0 0 0 0 Self-injurious Behavior ❑ 0 0 ,..,EI-- 0 0 Substance Abuse vEr 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ,� ❑ ❑ ❑ Runaway ❑ ,a ❑ ❑ ❑ ❑ ❑ Sexual Offenses / o IV ❑ 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 al 8 1 to this child e. e r : rr. 2:. .;&,4' °a .. '4 s• s ^3. , " c'.4 '! iiitaii t _ ' R kg'2� p k - 3RF'��f`.` '�` s�"?.k;. . x r e.ry_. .,.a ..... . .. . ( � a .. e'vv.mn%"r.0 w�s•.�31. itu�t�t„'.: 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 O Medical Needs (If condition is rated"severe", ❑ O O O El 0 0 please complete the Medically fragile NBC) Emancipation ❑ O O O O O O Eating Problems ❑ O O ❑ O O O Boundary Issues ❑ O O O O O ❑ Requires Night Care ❑ ❑ O O O O O Education ❑ O O O O O O Involvement with Child's Family O O O O O O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑I ❑ 11/2 ❑ 2 ❑ 2'V ❑ 3 ❑ 3'/Z 7 Weld County Addendum to the CWS-7A S-7A • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 4 L i .„ F•i (L� ,• 2S „, Cx1 'Y 4 All ! 3 v ..a .._s'..nFU#'`Vt..ra Fec».i`�`�t.#.:nL Age 0-10...$16.32/day ($496/month) County Basic r • Age 11-14...$18.05/day ($549/month) Maintenance Rate ois Age 15-21...$19.27/day ($586/month) $ +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care fr.{- 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) $29.59 21/2 +$.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) 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 th- : card WELD COUNTY BOARD OF SOCIAL 4S L ` SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: ,/.i i I! ►�i • v . � By 4_-f i!d _ /Ij — Deputy ' erk to the :'1 ( � Chair S. nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT McKeown, Anthony and Jessicca OF HUMAN SERVICES 722 Goodrich Ct Platteville, CO 80651 By: By: D're for By: as 93 9 Weld County Addendum to the CWS-7A UNA/S-/A(KIU-111/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 1-2--'\ by a !inbetween the Board of Weld County Commissioners, sifting as the Board of Social Services, on alf of the Weld County Department of Human Services, hereinafter called "County Departmerand, Means, Nathan and Lisa, Provider ID# 1601788, 2632 15th Ave, Greeley, CO 80631,r 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 cr contract and agreement is in lieu of and supersedes all prior purchase contracts between tlw 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-/A (1(10-10/99) 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 C W S-/A(K I0-10/99) 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 C -rk to the : ' - ♦ WELD COUNTY BOARD OF SOCIAL La``SERVICES ON BEHALF OF THE WELD • \COUNTY DEPARTMENT OF HUMAN ift �� ERVICES / ta5t `-7 By: By (t11){11, , J5�c2a Deput lerk to the Boa Chair Sig ature Approval as to Substance: 1rry PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Means, Nathan and Lisa OF HUMAN SERVICES 2632 15th Ave Greeley, CO 80631 By: By: irector BY: �ter. 01/1OAte 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Means, Nathan and Lisa 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 Oil� , 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#1601788. 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'O/ Weld County Addendum to the CWS-7A S-7A7A 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 011/2)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 02'A)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''/2 hour per day ❑1'/:) %:hour a day 02) I hour a day 02 '/s) 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 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) I I to 14 hours per week ❑3)Constant basis during awake hours 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? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%:) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3i:)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. ❑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%s)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 'g k'+ i m _ - W ,F�}y5 3 '4 . +i : t v � 4 t 9v Aggression/Cruelty to Animals 0 0 ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ 0 ❑ ❑ ❑ ❑ 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 ❑ 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ ❑ ❑ ❑ 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 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.I I to this child. f ) n _ ay�y y 'vim` $ '-•: «t _ §. * : S ,„ . Via+, ;S •/ A - • k .•.," ''..�. '4 ,,,,A V. • �,� .'4. rs n i 'I i . � . a� �` .;?.;,--/•..;l4,-;..,,,.� .. a�u ., t- ..v, ,€ ,. va 36;..., . . .xa s €'. 'w 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ 0 0 0 0 0 El please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 ❑l ❑ 1% ❑ 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 , try" ya)%s `v a ,: ik3� fz}in +a tt f _ 4 # u t 1 a <,+�.,,� .,r . q*�'aa ,'3s, + .. . �p + 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 ($586/month) _�444444� Respite+ Care$.66/da p' y ($20/month) , $19.73 1 ai'i +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 g, +$.66 Respite Care Total Rate=($23.67 day/$720 month) ui $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) rat $29.59 21/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 - +$.66 Respite Care Total Rate=($33.54day/$1020 month) �asd $36.16 3 1/2 4.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 �.r $39.45 TRCCF Drop Down a +$.66 Respite Care Total Rate=($40.11 day/$1220 month) AssessmenVEmergency v $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7/6 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- 'cas , WELD COUNTY BOARD OF SOCIAL 4s La SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN t8% %SERVICES / By: 1/. 1 /_' :. 41�. .i��;�j " �` � titetut_ X.c t Deputy ' erk to the Boa Chair ignature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Means,Nathan and Lisa OF HUMAN SERVICES 2632 15th Ave Greeley, CO 80631 By: By: ,tar, -'" irector BY y Ly. 9 Weld County Addendum to the CWS-7A S-7A (KI U-I U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT Q 7 1. THIS CONTRACT AND AGREEMENT, made this date, al) , V Zo l! by and between the Board of Weld County Commissioners, sitting as the and df Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Mellmen, Jeffrey and Letha, Provider ID#1547484, 352 Laurel Ave, Eaton, CO 80615, 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 aCi/-aa � t.. 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 LWS-/A (1(10-10/99) 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 Boar. WELD COUNTY BOARD OF SOCIAL v's lig:�1`��ERVICES, WELD TY DEPARTMENT OF HUMAN UN VICES O 11/42 By: .!%/f/-/ '✓_',�° ?:I�Ii� , �k. °/yam L Deputy k tot e Board � u!p n Chair Sign ure AU 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mellmen, Jeffrey and Letha OF HUMAN SERVICES 352 Laurel Ave Eaton, CO 80615 pp�� By: By:irector By 4\tHM 3 a0//- d if.3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the"Agreement") between Mellmen,Jeffrey and Letha 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 , 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#1547484. 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. 90//-07ay,3 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 DI 1/2)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 02%)Once a week 03)Two times a week 03%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1) Less than a'/z hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) I'/:-2 hours per day 03)2'/2-3 hours per day ❑3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%)5 to 7 hours per week 02) 8 to 10 hours per week 02%) I I to 14 hours per week O 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 use appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) I 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. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T I. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑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 al.1 to this child. i, i.^G54` t.a. . r. is � .. ;- ;.. .`. t S 4 a ``�;# r°'-0�•°'ems'..' . fr.li:1.c'q xa'c,ii.'m" !'Gay.....- .. ..e .,. a se, x '.' g4,-.,,.at=s , .......xiia1..€Car Aggression/Cruelty to Animals ❑ 0 0 ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ 0 ❑ ❑ ❑ 0 ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ ❑ ❑ ❑ 0 ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ 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/intensit of conditions which create the need for services that a''I to this child. h � t� Inappropriate Sexual 0 ❑ 0 ❑ 0 0 0 Behavior Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe', ❑ 0 ❑ 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 0 0 Eating Problems ❑ 0 0 ❑ 0 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ 0 0 0 ❑ 0 0 Education ❑ ❑ 0 0 0 0 0 Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/4 ❑ 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 • aJvt, • • . • ir,t� �, 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 4.66 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 r. $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 s L[, \ COUNTY DEPARTMENT OF HUMAN SERVICES O E1/42 By: Deputy 'erk'to the B Chair S' nature C AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mellmen, Jeffrey and Letha OF HUMAN SERVICES 352 Laurel Ave Eaton, CO 80615 By: By: Di ctor By: 9 Weld County Addendum to the CWS-7A 07, 3 LWS-/A S-/A(1(10-10/99) 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, Mena, David and Marie, Provider ID# 1510691, 2905 41st Ave, 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 arir- a�� 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 LWS-/A (KIU-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 B.- a/mow � WELD COUNTY BOARD OF SOCIAL ♦41\e Las SERVICES, ON BEHALF OF THE WELD �- OUNTY DEPARTMENT OF HUMAN ] RVICES • By Deputy ' lerk to the Boar:+rr► Chair Si nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mena, David and Marie OF HUMAN SERVICES 2905 41st Ave Greeley, CO 8063 By: By: '� Di ector Bye. 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") betwgenA o 18 Mena, David and Marie JUL 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-w✓~,I , 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#1510691. 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. aWS7A:2a9 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 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 ❑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? O 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%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%:)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 ❑I) 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 ❑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 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-7A S-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. rt r w t ' < SS rit t . - a '!1 -- a: c „� . ._...;, t ` `l. '"',x j'it M � :- ''" 5 x ,y -6 �4w` r fr � '}s;*,*t dra § � r iit.> � " t. ' + .,t 9 ,.. N a , to r 'y vr,; `, 5,d ,.... .. Aggression/Cruelty to Animals 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 O Self-injurious Behavior ❑ O O O O O O Substance Abuse ❑ O O O O O O Presence of Psychiatric Symptoms/Conditions O O O O O O O Enuresis/Encopresis ❑ O O O O O O Runaway ❑ O O O O O O Sexual Offenses ❑ O O O O O O 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..1 to this child. „''.' k s s .. ^s 'z.L....,"' #+ry a .e+eS=tw'Lat;',t ,. .,. ;:.,. _ .,... c•�� g� °'.,ft"aai,ea Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ 0 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ 0 ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ 0 0 0 0 0 El please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 0 0 Eating Problems ❑ ❑ ❑ ❑ ❑ 0 0 Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ 0 Education ❑ ❑ 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'h 7 Weld County Addendum to the CWS-7P (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE a '.; Age 0-10...$16.32/day ($496/month) County Basic ` j Age 11-14...$18.05/day ($549/month) Maintenance • Rate , t1 Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 7 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 112 +$.66 Respite Care y ., 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) , t $32.88 3 +$.66 Respite Care 7y4 Total Rate=($33.54day/$1020 month) ,....i $36.16 3 1/2 , +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 +$.66 Respite Care TRCCF Drop Down Total Rate=($40.11 day/$1220 month) AssessmentiEmergency a $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 Count Clerk to t Cti,p -' WELD COUNTY BOARD OF SOCIAL 4 b a� SERVICES, ON BEHALF OF THE WELD ' �! ER NTY DEPARTMENT OF HUMAN VICES 161i By: ✓/ il /. ,' ►�J7��''•'��it !Rile By, -L�'vi,.0 + /'7;-..Ci/c. Deputy ��rk to the Boar��.r►� t Chair Signature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mena, David and Marie OF HUMAN SERVICES 2905 41st Ave Greeley, CO 80634 By: By:, Dir ctor By:Ll"\f ki.1 , Ati V`1ci,-- ©i/Aq1; 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 4911 jot 6fYyq 1. THIS CONTRACT AND AGREEMENT, made this date, 7///// by and betWe5 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, Middleton, Brian and Deborah, Provider ID# 1537851, 2418 W. 24th 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 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 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 Cou rk to : . ` 1 WELD COUNTY BOARD OF SOCIAL � . 1. SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN r a SERVICES By: I✓/L� ��S//I"�i iL> �w'� �� B . dick, Depu-'�Clerk to the Chair Sig y ature ��►" AUG 7 2011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Middleton, Brian and Deborah OF HUMAN SERVICES 2418 W. 24th St Rd Greeley, CO 8063 By: O By: D rector By: 3 O// g&9S 1 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Middleton, Brian and Deborah and the Weld County Department of Human Services for the period from July 1,2011 through June 30,2012. The following provisions, made this 1 day of _O— , 2011, are added to the referenced Agreement. Except as modified hereby, all terms of thet 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#1537851. 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. c2I Weld County Addendum to the $1,13 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 ❑1/)2 round trips a week ❑2)3-4 round trips a week. ❑2'/z)5 round trips a week O3)6 round trips a week 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 ❑1)Once a month 01%)Two times month ❑2)Three times a month ❑2'/:)Once a week O3)Two times a week O 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 ''A hour per day ❑l'A) '/3 hour a day O2) I hour a day O2 %) 1'/2-2 hours per day O3)2'/:-3 hours per day O3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/) 11 to 14 hours per week 0 3)Constant basis during awake hours O3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1''/)5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3''/)21 or more hours per week 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. 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 ❑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. ilB a: a .. • •i. P : k.. 9 °'k'YY �..j ks "r'r'tivd4: +.$�w'Ya.=< 6+'t.'R- .,., ,� ✓ '-:x <. .v.^ 5.a,:ka..°�r'z.+`.. . w.. v . , -� .�. �mwCm5A.cc� ¢ c`ts 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 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ O O O O Sexual Offenses ❑ ❑ ❑ ❑ 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/intensit of conditions which create the need for services that a r 11 to this child. r'�.;t as �v s „,.. ... .F_„ .., „. . ;;� r s •' � r .n ,,krya�:�� i2 2 � is * c .. .• .. '.. ' H, � ? �g� 44 4 �tyyq �y, k Inappropriate Sexual Behavior 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", ❑ O ❑ O El O O please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ 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 ❑ 1'h ❑ 2 ❑ 21/2 ❑ 3 ❑ 31/4 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) to $19.73 fly +5.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 4.66 Respite Care Fu Total Rate=($23.67 day/$720 month) $26.30 2 +5.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 112 t +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 I., 4.66 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 i Total Rate=($40.11 day/$1220 month) AssessmenUEmergency $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 i,La COUNTY DEPARTMENT OF HUMAN • SERVICES R eryn�y •861 S•1�J-��•� ^ By: /I /�/ /� / �d ,/a.�i�/�a�. By. c%.1i Deputy erk to the�:��1 � a Chair Si nature l AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Middleton, Brian and Deborah OF HUMAN SERVICES 2418 W. 24th St R Greeley, CO 80 4 By: By: D ector By: _Le02(VA 07,0k6 9 Weld County Addendum to the CWS-7A LWJ-/A(IC IU-IU/99) • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT W/'JR 1. THIS CONTRACT AND AGREEMENT, made this date, 7 /IL/ by and beldvee 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, FS/ Moore, Earl and Patricia, Provider ID# 1517579, 135 Poplar St, Lochbuie, CO 80603, 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-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 I,W S-/A(K10-10/99) - 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 t1 • 1 WELD COUNTY BOARD OF SOCIAL 4 -a'` SERVICES, ON BEHALF OF THE WELD 7-3 COUNTY DEPARTMENT OF HUMAN k SERVICES By- r%mil ��1ii 11r�' B ,C i ;4- Deputy'' erk to the ' '')U Chair Sig ature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Moore, Earl and Patricia OF HUMAN SERVICES 135 Poplar St Lochbuie, CO 80603 By: J )0� By: D ec or 1 By: 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Moore, Earl and Patricia 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 , 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#1517579. 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. c9C//02029_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 perforniance 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 ❑2)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 01%)Two times month 02)Three times a month 02%)Once a week 03)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a ''/3 hour per day 01%)1/2 hour a day 02) 1 hour a day 02 '/:) 1'/r2 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 DI)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'%) 1 I to 14 hours per week 0 3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 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 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-7F (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. _. S r"i2 ' ::4>i. ry . , . .. .., .. , � L' f>. � ., .,`NaA:.:^.,_S'+�, ....: xxrwu Aggression/Cruelty to Animals ❑ 0 ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS-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 r r I to this child. W.Sit^t�" ge9a`` '; 4 F . f . 1 4q, - tt,,� 5'X$ 4 , b y y y+ v8 .§'? „, 5.-.a1', cP..e l.xxk4 Inappropriate Sexual Behavior O O ❑ O O O O Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ O ❑ ❑ ❑ Depressive-like Behavior ❑ O 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 ❑ O O O O O O Boundary Issues ❑ ❑ O O O O O Requires Night Care ❑ ❑ 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 Ell ❑ 11/2 ❑ 2 ❑ 21 ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7/ (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES • NEEDS BASED CARE RATE TABLE • qE 3"f G3 k i FKi )d t"3frvk R rv'. a, r �r '� a om`'V..?.� ^ tE& ? � ° Ei ,1� x+ o v F M1f d ,. . .n»av orc�u:.=x+ sx§re, ,r sx:.nc. • i7C' arh•�.nw;. r a X : r,. ...:..Y?,.o-aa: +,.:F :C' $, .€+₹?"'.' .,°t�._.ua<.,..,:: Age 0-10...$16.32/day ($496/month) County Basic 4,X, 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) $23.01 1 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) arf t;' $29.59 2 1/2 s�v: +$.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) 4.41 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) AssessmenvEmergency Rate $30.25 day/$920 month(Includes Respite) 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 Clem ?s^•Fr�,r. WELD COUNTY BOARD OF SOCIAL • L aS. SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN •"'y -� SERVICES By: 111 (u ( L//Kt_[ �. Deput clerk to the:' .,ri Chair Sgnature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Moore, Earl and Patricia OF HUMAN SERVICES 135 Poplar St Lochbuie, CO 80603 By: By: Dir ctor Byq/arZ t 9 Weld County Addendum to the CWS-7A LAWS-/AIKIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 21!11 JUL 13 pp tin1,1. THIS CONTRACT AND AGREEMENT, made this date, Dr1 i I( by and Ketv✓2en 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, Parker, Brian and Beryldell, Provider ID# 1538709, 230 N 53rd Ave PI, 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 aO//cS_3 L W S-/A(RIO-IV/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(K I U-IU/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 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 Jerk to the : .. • 'tis ELD COUNTY BOARD OF SOCIAL / RVICES, ON BEHALF OF THE WELD '//(isu • e�`UNTY DEPARTMENT OF HUMAN S VICES Deputy,#'rk t• the Board Chair S' nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Parker, Brian and Beryldell OF HUMAN SERVICES 230 N 53rd Ave PI Greeley, CO 80634 7)M°By: vJ� By: Di ector By. 3 c2C//- 67075,3 • ` WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the " reement") between Parker, Brian and Beryldelaii JJL 13 tin 9 y0 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 l7 , 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#1538709. 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/A o7O7 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 emmnerated 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. TFIE 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 DI)One round trip a week DI%)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'/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'''/ hour per day 01%) 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 01%)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) I 1 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? O 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 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. ❑1%s) 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 ❑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..I to this child. 'a y( •. 4 4 �"R vk :J. : iy� p )"li yam° it. ,y" .._ arz..Tw F.&ir� s�°� �'X�3U6;.en.x_a .0 e.,. ., ....nw Aggression/Cruelty to Animals O O O ❑ D 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 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 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 S-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. i� .I'i .: -I i - .; = ti t3,73......�' ' •t'4 > �`" ,� +A* (5 Y c , : 1 ': a§ r° 5 tl ::$: a•,�3$erx�nxs.x„v` ��.�*�,�.. � ' rz ..� s .. 1...: r... u, _�` Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ O O O O O O Delinquent Behavior ❑ O O O O O O Depressive-like Behavior ❑ O O O O O O Medical Needs (If condition is rated"severe, ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ O O O O O O Eating Problems ❑ O O O O O O Boundary Issues ❑ O O O O O O Requires Night Care ❑ O O O O O O Education ❑ O O O O O O Involvement with Child's Family O O O O O O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/4 ❑ 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 L� 4 . F t t ��' _ to 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 4.66 Respite Care Total Rate=($23.67 day/$720 month) 474 $26.30 2 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) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 � +$.66 Respite Care , 3e Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$66 Respite Care . 4 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 SERVICES, ON BEHALF OF THE\ IL/� � COUNTY DEPARTMENT D F HUMAN y i SERVICES � wy�t162�I i By: '� .i/ri _* .ii /�; � By �� i� L E/A" C- Deputy 'erk to th�i(u ;04. Chair Si nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Parker, Brian and Beryldell OF HUMAN SERVICES 230 N 53rd Ave PI Greeley, CO 80634 By. By. `C it ector By: 0170//- 9 Weld County Addendum to the CWS-7A I,WS-/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, /S / j i. Ian nlpy.Pgd t rj b the Board of Weld County Commissioners, sitting as the Boar dd of S cialSWIM", ontelfalf the Weld County Department of Human Services, hereinafter called "County Department" and, Pierce, Kris and Larry, Provider ID# 1586620, 3017 54th Ave, Greeley CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 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 1.W J-/A(K I U-I U/99) 211. 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.,WS-/A(KIU-IU/99) o ,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-, : � ''�r WELD COUNTY BOARD OF SOCIAL .` La%` SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN t kt;. SERVICES • By: l iW .Os_�,`�> Fire By X41' cri_ Deput Clerk to the Bo Chair Si nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pierce, Kris and Larry OF HUMAN SERVICES 3017 54th Ave Greeley CO 80634 By: By: 7'1 /lv0 a ��t-c.e +At Dire for By: Oy7 3 aow-c c WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Pierce, Kris and Larry and the Weld County Department of Human Services for the period from July 1,2011 through June 30, 2012. The following provisions, made this 5 day of T IA_t y , 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#1586620. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. e// 02a 3 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 ❑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 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? O Basic Maint.)No educational requirements ❑1)Less than a ''/3 hour per day ❑1%:)'/x hour a day 02) I hour a day 02 %) 1'h-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 011/2)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/z) I I to 14 hours per week ❑3)Constant basis during awake hours ❑3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 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.) DI) 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-7/1 (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. 4.. •::: 1^. ' 3-.. A .. . . .� ... .'.. "."a"':: w s'.'.Prprk;v+0i: air v.. ' `.C _ r...�'�u`*t x : ::.. ...,4 , ?."x,2'u"x- ':�.... S ; * ' ' ^ ... �'„ ,.a..,",�3„4* w:•'�.b'.r"� ., ' 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse O O O O O O O Presence of Psychiatric Symptoms/Conditions O O O O O O O Enuresis/Encopresis ❑ ❑ ❑ ❑ O O O Runaway ❑ ❑ ❑ ❑ O O O Sexual Offenses ❑ ❑ O O O O O 6 Weld County Addendum to the CWS-7/1 (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..l to this child. ,...;74',:,-;:,.,,E,,:::iit;i:;:::::1;:::iiriHt,,z.:,,i,:.;:iti s a.,. ? . i.' . ^i i'a?�.'r'.2.'v ::" :. >. '��' TS "'t �dPl7�` ,'�..' �y .j 41;1 t k .: k 4 S4 s Imo:....'...e...,.. ,c.? .. '4..3:".<. .. w.„, .. ....................._.. :.:.. . .a®.,v .& �. .m„% Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 ❑ Boundary Issues ❑ ❑ ❑ O O O O Requires Night Care ❑ ❑ ❑ ❑ ❑ 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) III 0 ❑1 El 11/2 ill ❑ 2'/z ❑ 3 ❑ 31/2 7 Weld County Addendum to the CWS-7/ (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE I e t G . tx S r Age 0-10...$16.32/day ($496/month) County Basic 41 Age 11-14...$18.05/day ($549/month) Maintenance t' Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 . +$.66 Respite Care t,ln. 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 4.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 API 2 112 4.66 Respite Care Total Rate=($30.25 day/$920 month) 1101 $32.88 3 4.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 112 Thui +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$. Respite Care Total Rate=($4011 day/$1220 month) Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 8 Weld County Addendum to the CWS-7t • 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 ♦IS SERVICES, ON BEHALF OF THE WELD \rya COUNTY DEPARTMENT OF HUMAN J/ r x►r �`, SERVICES v . kel? .' By:/I // 1, i��_lhi %hlY�r By Lit1c i iL ),l-'')113 LOLL, Deputy if ark to the . . * \ Chair Signature / AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pierce, Kris and Larry OF HUMAN SERVICES 3017 54th Ave Greeley CO 80634 By: By: „7-,c4_4; i/ PLEA i ector � ((// By: c• cat's 9 Weld County Addendum to the CWS-7A I,WS-/A IKIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES JUL 13 An 9 56 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 ocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Pluma, Mike and Annette, Provider ID# 35126, PO Box 34, Kersey, CO 80644, 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 UWJ-/A(1(10-10/99) 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(K I U-1 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 th`a q La WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD y o ;COUNTY DEPARTMENT OF HUMAN tui t ,/ By: ' %//./_ a �! li�_�1'jil- By:" 7G ,�1u 1 �1 i , LAtt z— Depute lerk to the Boa� !J �► ' Chair Sig?lature / Approval as to Substance: PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Pluma, Mike and Annette OF HUMAN SERVICES PO Box 34 Kersey, CO 80644� By: By: ottu W�!�� I W' e.A__ 72/4 irector , P By: 74/I/ 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Pluma, Mike and Annette and the 4// �� Weld County Department of Human Services 1 for the period from July 1, 2011 through June 30, 2012. Inp The following provisions, made this f day of —SW , 2011, are added to the referencedss Agreement. Except as modified hereby, all terms of the *cement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#35126. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 46 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. 0120/7-0702 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'/z)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 ❑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? O Basic Maint.)No educational requirements 01)Less than a''/z hour per day 01%) 1/4 hour a day 02) 1 hour a day 02 '/z) 1'/z-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 01)Less than 5 hours per week 01%)5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week O 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 au 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'/z) 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 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-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 al.1 to this child. }""� ' � t$ " ,' iiE 1 tl J Y f a i 'k ti h C.: dw �. . y d t 2 - gkv m�S.:.4va7 t A14 ti Aggression/Cruelty to Animals ❑ 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 ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ O O O O O O Enuresis/Encopresis ❑ O O ❑ O O O Runaway ❑ O O O O O O Sexual Offenses ❑ O O O O O 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 a r 81 to this child. x�uof p ', % '4 "yi6vu}+:ux ia Vti '$ 1v4.ib *.:1,:''',.: L .. .. . 344' § gi d k�uy�� , k <sa a to Asa'<. re D `M A' q`{*.a�.a..,s3?a,r �., .. . ,..�e'-. y a...,.:* .� ....,>? _k,� a . .F e₹f,,, .._.: ,. z aa.45 ¢�. A�` � � Inappropriate Sexual Behavior O ❑ O O O O O Disruptive Behavior O O O O O O ❑ Delinquent Behavior ❑ ❑ ❑ O O O O Depressive-like Behavior ❑ O O O O O O Medical Needs (If condition is rated"severe", O ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ O O O ❑ O O Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ O O O O O O Requires Night Care ❑ ❑ ❑ 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 ❑1 ❑ 172 ❑ 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 • . • is ,. ,, b x t 1 7, n•r e`. `at•_.ats:₹v.u�'F Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate g Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.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) $36.16 3 1/2 +$.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 to t e oard WELD COUNTY BOARD OF SOCIAL • SERVICES, ON BEHALF OF THE WELD Q'�`� COUNTY DEPARTMENT OF HUMAN - -� SERVICES 1861 fir O By By: Z LiCtx Depu Clerk to th �:ir�� ; 1 Chair Si ature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pluma, Mike and Annette OF HUMAN SERVICES PO Box 34 Kersey, CO 80644 1 n By: By: 'rector By: cQt7//-A9�3 9 Weld County Addendum to the CWS-7A S-7A LWS-/A(Klu-lu/YY) C INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 714 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, Ramos,Julian, Provider ID#37631, 2029 17th St, 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 ow/-day= LWS-/A(KIU-IU/99) •,11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 (.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 WELD COUNTY BOARD OF SOCIAL • rte % SERVICES, ON BEHALF OF THE WELD •+11v �, COUNTY DEPARTMENT OF HUMAN �+ 7Q 1 -, SERVICES 1 t Depu Clerk to the •:yrt �\ � Chair ig ature Approval as to Substance: PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Ramos, Julian OF HUMAN SERVICES 2029 17th St Greeley, CO 80631 By f y rector By: 3 aoi/ asp WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") betwe Ramos,Julian �1 JUG 12 A IQ SO 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 tT 2011, are added to the referenced Agreement. Except as modified hereby, all terms of the 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#37631. 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'//,-a1ay{g 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 02)3-4 round trips a week. ❑2'A)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 ❑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 011/2)1/2 hour a day 02) 1 hour a day 02 'A) 1'h-2 hours per day 03)2'/2-3 hours per day ❑3%:)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ 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 ❑2A) 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 ❑11s)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.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%z)Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/:) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 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-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.... a, :.,.xr,.•. . ,.t,A4..• .....,....•.,. . - ,. ,,. .s 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions O O O O O O O Enuresis/Encopresis ❑ O O O O O O Runaway ❑ ❑ O O O O O Sexual Offenses ❑ ❑ O O O O O 6 Weld County Addendum to the C W S-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..I to this child. -_ ^S aet#a3ti3�.+ inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ O O ❑ O O O Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 Boundary Issues ❑ ❑ O O O O O Requires Night Care ❑ ❑ 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 Ell ❑ 1'/ ❑ 2 ❑ 2'/ ❑ 3 ❑ 31/2 7 Weld County Addendum to the CWS-7/ (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE n T-c?*a vw tom.. "�st x v �a F' x �+ { n t � ? .0 �rSam s { :,,�.ca sSac Sy ,+r .a..... ,�kx..,_+.,u.. `�'x` s v`' t$ �� xa�7 '° ytij x3 ,v;. t •� i 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) $19.73 1 y +$.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) 4,5 $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) 9 $32.88 3 +$.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-7i • ' 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 A b Lam COUNTY DEPARTMENT OF HUMAN SERVICES yy,am�at O By �� it ^�a��rJ A,, By. tliytlti 17,2' '--. Deput Jerk to th�i� F�' °� � Chair gnature AUG 1 7 2011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Ramos, Julian OF HUMAN SERVICES 2029 17th St Greeley, CO 80631 By: B ` Dir or By: 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGRIT Ig ,51igS5 ` 1. THIS CONTRACT AND AGREEMENT, made this date, , o1y ICI ?191 I by and between the Board of Weld County Commissioners, sitting as the Board bf Sodial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Redding, Christopher and Sonja, Provider ID# 1524128, 2305 42nd Ave, 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. LWS-/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 GWS-/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 ;S L WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN 1462 e - SERVICES 1861 1 , BY .:ii i.i ►.I�ia.'�!�.��' ��_ 44 By: �l�uc Depu / erk to the Boor t1' �+ �► Chair Signature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Redding, Christopher and Sonja OF HUMAN SERVICES 2305 42nd Ave Greeley, CO 80634 By: By: .014t.--9/44 Dir ctor By: C0y. 2in,r 3 77 WELD COUNTY ADDENDUM // To that certain Individual Provider Contract for Purpose of Foster Cart 19 +y Services and Foster Care Facility Agreement(the "Agreement") between 9 $5 Redding, Christopher and Sonja and the Weld County Department of Human Services for the period from July 1,2011 through June 30, 2012. The following provisions, made this /O day of JJI , 2011, are added to the referenced Agreement. Except as modified hereby, all terms of t�ement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1524128. 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 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 ❑2)3-4 round trips a week. ❑2/)5 round trips a week 03)6 round trips a week ❑3'/:)7 round trips or more 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 ❑I)Once a month 01%)Two times month 02)Three times a month ❑2'/i)Once a week 03)Two times a week ❑31/2)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%)'%hour a day 02) 1 hour a day 02 %) 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 ❑I)Less than 5 hours per week 01%)5 to 7 hours per week 02)8 to 10 hours per week ❑2%) I I to 14 hours per week ❑3)Constant basis during awake hours ❑3/)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 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. ❑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%)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 CW S-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..l to this child. �•1::.---4::'. ''';'-`.t.„ .- , r �J y. A 1 ....-,::::7,:i ;$ ilia h,y H. •;h w, .W.: . ..•. . .::.`.-aft..a17 x Ails Aggression/Cruelty to Animals ❑ 0 0 0 0 0 0 Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7P (Example only do not complete)• WELD COUNTY(ExhibitB)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. ..i:t.:,ii. �qq. s c a: g i' il;:aci;..citilffet;tiaH.:::;,,:;;;;;;; ;Iiii„i3;..1::::::,. , :,,.., . ,.' . . 7 ' ' ' I:An:10;4:k J1.:..'.". . Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ O O O O O O Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ O ❑ Medical Needs (If condition is rated"severe-, O O O O O O O please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ O O O O Boundary Issues ❑ ❑ ❑ ❑ ❑ O O Requires Night Care ❑ ❑ O O O O O Education ❑ ❑ ❑ ❑ ❑ 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% O, 2 ❑ 2V ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS-7i (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/$620 month) 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) ....Y $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care T.h Total Rate=($33.54day/$1020 month) $36.16 if 3 1/2 +$.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 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 WELD COUNTY DEPARTMENT OF HUMAN ILa%;ERVICES By: 1 ��//,� �! . .r r'f' 'y:_tilt to i Deput lerk to the Bo. �1M j Chair S. nature tit ®(f •Nit AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Redding, Christopher and Sonja OF HUMAN SERVICES 2305 42nd Ave Greeley, CO 80634 By: By: i°1 i ector By: St- K "?D//- aK1/4,3 9 Weld County Addendum to the CWS-7A LWS-/H (KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT ENT //�� 1. THIS CONTRACT AND AGREEMENT, made this date, `ietri Aejil by and between the Board of Weld County Commissioners, sitting as the Boar of S cial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Reussow, Robert and Tracy, Provider ID# 103704, 4124 W 8th Street, 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 LWS-/A(K IU-10/99) 1.1. 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-/H(KIU-I(1/99) • 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 :r? : % WELD COUNTY BOARD OF SOCIAL \Lam ♦SERVICES, ON BEHALF OF THE WELD OUNTY DEPARTMENT OF HUMAN ERVICES t O i1/42 , , By: �By, cic% 1Jl _y Deputy ,' erk to the Boar`.%'((U VC Chair Sig ature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Reussow, Robert and Tracy OF HUMAN SERVICES 4124 W 8th Street Greeley CO 80634 By: By: hector B � . ... �� 3 • WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the"Agreement") between Reussow, Robert and Tracy 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 L15 , 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#103704. 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. fY/-ealo? 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 (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 E(1)One round trip a week 01%)2 round trips a week ❑2)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week 93%)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 011/2)Two times month 02)Three times a month 02%)Once a week 03)Two times a week 93%)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? El-Basic Maint.)No educational requirements 91)Less than a '/z hour per day 011/2) '/1 hour a day 02) 1 hour a day 02 %) 1'h-2 hours per day 03)2'/:-3 hours per day O 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? asic 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 '/) 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 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.) 91) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) 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. ❑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(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/intensit of conditions which create the need for services that as el to this child. � Y Tad r # Aggression/Cruelty to tin 9n/ i Animals Verbal or Physical 40//1 IA i Threatening ❑ 0 ❑ ❑ ❑ ❑ 4(11/S' ,* lld ge� Destructive of / , Property/Fire Setting 0 ❑ 0 0 0 0 ig Stealing ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior VV / M' AKifif Substance Abuse 0 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ 0 Runaway V ❑ 0 0 0 0 0 Sexual Offenses 0 0 0 0 0 0 1 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/intensi of conditions which create the need for services that a''I to this child. *7'upa&, 3 vg i a a. ::s.• w, ;c*va, tv; t �,ah'as 3 , q. x ti c � ryw.ys, hur w ;# °'w> �� Xr‘04i i 4 :, i ':.. 41 4 "+.. t -z6, •sb...^x, of ' ' ,'y*, ,v t %. � N .� • ss,r.'-€Y�'i*'k&: ,usa". ..... ` .... .� ... . . .. .s'°�:;x�.. . _._. ; . .. ... an+.s- r,'� v3�::.:. fiv Inappropriate Sexual Behavior O O O O O O Disruptive Behavior ❑ ❑ ❑ ❑ d ❑ ❑ Delinquent Behavior d O O O O O O Depressive-like Behavior kli O O O O O O Medical Needs (If condition is rated"severe", 0 ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems '6 O O O O O O Boundary Issues ❑ O O O O O O Requires Night Careifil SU// (/ 411/ d?%f/ Education /i // ' -0 O O O O O O Involvement with Child's Family O O 0 O O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑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 . stag z 4 as im"a3 E/"fi } a µqa + e�UUw{ ;,,ccsyyy4f, z r c i x£54M,d�"SV `YUYa»a:YiS�+3b��,a.,+3t ua SJ:.t�II u'�ivrc Yai' u3t Ta A•e 0-10...$16.32/da $496/month County Basic T Aso 11-14...$18.05/de $549/month Maintenance t,.�n 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) $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) gYI $26.30 2 +$.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) $36.16 3 112 +$.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 q WELD COUNTY BOARD OF SOCIAL S E fad SERVICES, ON BEHALF OF THE WELD 'COUNTY DEPARTMENT OF HUMAN �� ERVICES 1861 t / ` By: °c. ,�By: C'1 llk L ?u ; Deputy perk fo the Boa i t H ti > i Chair Si nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Reussow, Robert and Tracy OF HUMAN SERVICES 4124 W 8th Street Greeley CO 80634 By: By: D ector • oy/-0202 9 Weld County Addendum to the CWS-7A r WS-/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, 7h// 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, Ritter, Thomas and Deborah, Provider ID# 1554009, 10151 Devonshire St, 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 fostteare services. The County Department or any duly authorized agent may request such servic to be provided to any child at any time within the limits of the certificate and without prior note. 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 condttions hereof. r The Provider agrees: „ct 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 RC/t- 0702 3 r UWS-/A(K10-10/99) 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. es 18. To fully comply with the Minimum Rules and Regulations for Foster Farjky Homes or Specialized Group Facilities. r - ry 19. Not to enter into any subordinate subcontract hereunder. T 20. To keep such records as are necessary for audit purposes by state anaiederal personnel. The records shall document the type of care and the term during which ca ejs provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. o y 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 • UWJ-/A 1K1U-111/99) , 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. r- 13. To assure that the service described herein has been accomplished and Wfecord made thereof on a case by case basis. a 14. To provide notice of hearings. 4.. 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 etas WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE z-fiWELD COUNTY DEPARTMENT OF HUMAN � SERVICES By: ii L/_ a�i _Y/Y tri \ By:` 424 Vi - id/2er A-- Deput Jerk to the Bo��:j��rl Chair Sigrtu / AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Ritter, Thomas and Deborah OF HUMAN SERVICES 10151 Devonshire St Firestone, CO 80504 By: V By: Dir ctor By: 3 0?C :9O7 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the"Agreement") between Ritter, Thomas and Deborah 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 theL 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 r— ID#1554009. 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 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?ry 07 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. S 8. The Director of Human Services or designee may exercise the following remttal 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 deified to mean incorrect or improper activities or inaction by the Provider as outlined irtrthe State Department Staff Manual Volume VII and/or County Department Policy andFrocedure 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 InternJatabase On-line System (FIDOS). c 8. Read, be familiar with and agree to the terms and conditions as set forth in thefFoster Parent Handbook which can be accessed through FIDOS. `.c) 9. Maintain/update information in the foster child's binder. The binder will be r€Viewed on a monthly basis and signed off by child's caseworker and/or the provider's Potter 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) emmib t_ r— N Co 'L1 O 4 Weld County Addendum to the CWS-7A S-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 ❑1'/z)2 round trips a week ❑2)3-4 round trips a week. ❑2'/z)5 round trips a week 03)6 round trips a week ❑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 ❑1)Once a month 01%)Two times month 02)Three times a month ❑2'/z)Once a week 03)Two times a week ❑3'/z)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O Basic Maint.)No educational requirements ❑1) Less than a''/x hour per day 011/2) 'A hour a day ❑2) 1 hour a day 02 '/z) 1'/z-2 hours per day 03)2'%-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 ❑I)Less than 5 hours per week 01%)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3'/z)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ 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 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%)21 or more hours per week Comments: _ v • A 1. How often is CPA/County case management required? (Does not include therapy) ti ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. 4' (i.e.mutual care placements.) ❑l) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/z)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑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/intensit of conditions which create the need for services that a..I to this child. F I4 $4c`'kY - '":ravg � ' ;;;;I':'�� It 3l : fit g , g_r s .i`'�4. i. � o-f a 'S�e '�'� ce S#'IIA;2 ;t., . 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 e1 Enuresis/Encopresis k Runaway 4. s. ❑ ❑ ❑ ❑ ❑ O 0- , �: 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/intensit of conditions which create the need for services that a..I to this child. �"},,..`� ` k ui! .1' `adwC • i k4Y .: r P A'a S 1,°&'^K Y4°"e§ ' '^a, � y •4 t ,•.. <r> i'�`+"fi d�it e »,s • : .si . ,_,. .. ,eR k 4 a v , . . . #.:.Py4r,x.k"s:Sva ,. .. .. 3-a:'�:Mv aS. .k?9 x +, ma:" ' 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 ❑ al Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ aD T Boundary Issues ❑ ❑ O O ❑ ❑ ❑y G to Requires Night Care ❑ O 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''A ❑ 3 ❑ 3'/ 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE • S .Y1�rt ,.• ni • e .. .�t �q i • , • f r�• 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 '.I Total Rate=($23.67 day/$720 month) c $26.30 c 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) rti $ CD $29.59 —D 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 O0D 3 +$.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) d $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency ..1.-1; $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 Clef `,i'M % WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE COUNTY DEPARTMENT D F HUMAN � SERVICES • By: ' � >%/ / / i �� Iii �=� '� By: , ti Lc -/7-4 Deputy erk to the Board r Chair ignature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Ritter, Thomas and Deborah OF HUMAN SERVICES 10151 Devonshire St Firestone, CO 80504 By: By: Di ector By: 0 L C r C.D O O 9 Weld County Addendum to the CWS-7A S-7A LWS-/AtKIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 2 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 /2 the Weld County Department of Human Services, hereinafter called "County Department" and, Roderick, Douglas and Kelli, Provider ID# 10994, 3110 57th Ave, 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-/A(K10-I0/99) 1.1. 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 L W J-/A(K 1U-10/99) 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 to th-vf' WELD COUNTY BOARD OF SOCIAL F.L SERVICES, ON BEHALF OF THE WELD 3 I COUNTY DEPARTMENT OF HUMAN • SERVICES 1861 / By: ��` / � 'r. 'is/I ..•',ct By: AytaLtl Deput,rlerk to the Bti;T`Uj u 11 Chair Sig ature r �...r�Approval as to Substance: PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Roderick, Douglas and Kelli OF HUMAN SERVICES 3110 57th Av- Greeley C• :0:34 By: By: Di ctor By: 3 aC/i-A72 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Roderick,Douglas and Kelli 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 iT 2011, are added to the referenced Agreement. Except as modified hereby, all terms of the 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#10994. 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 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 ❑2)3-4 round trips a week. ❑2''/)5 round trips a week 03)6 round trips a week ❑3'/:)7 round trips or more 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'/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 Dl) Less than a''/z hour per day 011/2)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 01)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 ❑1)3 to 4 hours per week 011/2)5 to 7 hours per week ❑2)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. 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) Dl)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. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ 0 0 ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ 0 0 0 0 0 0 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 a..1 to this child. q"C{No59wti4YF A7 b.M1 7::-7-'7,77".7.' YF 3F N",i 4,•C n :. `ft::',..!''M '2 . • a es . ;77-1?; ae `M 'a"4'".t'° 44,.,. y t n *+z kin ; 4 atttt.wa?,,.�.i4' 3t:a,.:4 a, .: .... . . .,. .. ..::1'....: C. ,."x. S •at. .... I. :o. t4xAtR.' 5: Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ O O O O O O Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ ❑ ❑ O ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ O O ❑ Eating Problems ❑ ❑ ❑ O O O O Boundary Issues ❑ ❑ 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 ❑ 1''/ ❑ 2 ❑ 2''/ ❑ 3 ❑ 3'h 7 Weld County Addendum to the CWS-7P (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE•F} I a SS L •$ `Y {o�d'lai4 bit �'t<w # 'f'�"` 3v .3 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) $23.01 1 112 +$.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 4.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 4.66 Respite Care ) Total Rate=($33.54day/$1020 month) b:.. $36.16 3 1/2 +$.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-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 r % WELD COUNTY BOARD OF SOCIAL 1861- i 1 ' l'a`\SERVICES, ON BEHALF OF THE WELD OUNTY DEPARTMENT OF HUMAN J� ( ERVICES By �� % �� n�:.y P I �� I By. ' 11 iL Deputy ' erk to the Board" Chair Sig ture AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Roderick, Douglas and Kelli OF HUMAN SERVICES 3110 57th Ave Greeley CO : 4.34 By: to A 2 By L rector U _ By 1 lt�l a©//-calag3 9 Weld County Addendum to the CWS-7A l-WS-/A(KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7 // /// 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, Rogers, Jeffrey and Tami, Provider ID#1550689, 5221 Bowersox Parkway, 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. • L W S-/A(K I U-I U/99) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 LWS-/A (KIU-IU/99) h. 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. alt4U1W2O nAjcC U 1 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 '•-?M WELD COUNTY BOARD OF SOCIAL 4f4 La SERVICES, ON BEHALF OF THE WELD > t ''S COUNTY DEPARTMENT OF HUMAN tfl' , SERVICES r ai"g / By' .4 i.. /f��Ii a Lrr... � 4ALI_- ti Defy erk to the B °Li\ I\ Chair Sign ure Approval as to Substance: PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Rogers, Jeffrey and Tami OF HUMAN SERVICES 5221 Bowersox Parkway Firestone, CO 80504 By: By. irector A ' d 3 0267//-olV WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Rogers,Jeffrey and Tami and the Weld County Department of Human Services for the period from July 1, 2011 through June 30,2012. The following provisions, made this t day of i 1.4 , 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#1550689. 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. 0?D//ca y� 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 2 Weld County Addendum to the CWS-7A 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; 3 Weld County Addendum to the CWS-7A violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? ❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1'%)2 round trips a week O2)3-4 round trips a week. ❑21)5 round trips a week O3)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 O2)Three times a month ❑2'/)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 of special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a '''A hour per day ❑l'A)'/z hour a day ❑2) 1 hour a day O2 '/) 1'/:-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 ❑l) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%:) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3%:)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing,grooming,physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/x)21 or more hours per week Comments: A I. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) DI)Face-to-face contact one time per month with child and minimal crisis intervention. 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) ❑l)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- • (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. ? .gg ' t Aggression/Cruelty to Animals 0 0 0 0 0 0 0 Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 ❑ 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS. • (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 9 9 1 to this child. w ., : .` r ° Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 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 ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ 0 0 0 0 Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ ❑ ❑ ❑ ❑ 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 2%2 ❑ 3 ❑ 3'/2 7 Weld County Addendum to the CWS• I • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE a + ""3rc�ra�' ; n4'k mokj a ° it v 7 :s,r �� a�tg¢o- 5 "„ ' [!�s'6ny�a s x" 5 "''kyz• + "'' (¢r.('d .),:a n t wfb V� l� La'�" "" r2aiSv4 i. i5d z$. �'Q{ � �: ≥es"a , x '� 'h . F'.n YS• o-s _} ,'f�}.a k;l,,�.,�•{,� fim s . . xGF°V.AYk -4`�"J `lE2 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) ricr $26.30 2 +$.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) $39.45 4 +$.66 Respite Care TRCCF Drop Down Total Rate=($40.11 day/$1220 month) AssessmenUEmergency AT $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 r SERVICES, ON BEHALF OF THE WELD s La♦ COUNTY DEPARTMENT OF HUMAN SERVICES JA Deputy'lerk to the a‘ Chair Sig ture AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Rogers, Jeffrey and Tami OF HUMAN SERVICES 5221 Bowersox Parkway Firestone, CO 80504 By: By: pi ector ON y: /r/ 9 Weld County Addendum to the CWS-7A CWJ-/A(KIU-IU/99) • • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT JUL 1 D WI 10 14 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, Rush, Phillip and Shannon, Provider ID# 1556437, 2540 S Flanders Ct., Aurora, CO 80013, 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 LWJ-/A(KI V-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) , , , A. 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 4-72,7#9, SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES 18661/1•,, t1 By' �/ /! �.� .b�.�T k ' /I ./A EA L , 4�� ,�/l-, Dep..*y Clerk to the B ( . \ Chair Si nature 'thy I Approval as to Substance: ' PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Rush, Phillip and Shannon OF HUMAN SERVICES 2540 S Flanders Ct. Aurora, CO 80013 By: By: Lo4 , By: 3 0W/-aay.S • WELD COUNTY ADDENDUM To that certain Individual Provider Contract for P osq pf fpsteerrCCare Services and Foster Care Facility Agreement(the " gree e ) }Qrly Rush, Phillip and Shannon 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,�Iy , 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#1556437. 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 4111 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 ❑l)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 ❑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 ❑1)Less than a ''/z hour per day ❑1'/) 9:hour a day 02) I hour a day 02 %) 1'h-2 hours per day 03)2'/2-3 hours per day 03%)More that 3 hours per day Comments: P O. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1'%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond ace 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 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.) ❑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 timesper 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 ❑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 :o''tihfr:::111:::::::111:;141f4P11::::1:::: h ff:. -`�,,� • % ''...":,...;:i•:, t t} "' . x� �7' 11- '...1i p £ L �,xd.-A:* . .£ 4 . YT + i.1..:" .__9, : ,�:n".� . "e+. a.. , . . ..,. .> . .t ..... s. � rya Aggression/Cruelty to Animals ❑ 0 0 0 0 0 0 Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions O O O O O O O Enuresis/Encopresis ❑ ❑ ❑ 0 0 0 0 Runaway ❑ ❑ ❑ ❑ ❑ 0 0 Sexual Offenses ❑ ❑ 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/intensit of conditions which create the need for services that a..I to this E, child. .774: ,y.„ "y : 'i ->:x fr(Te`,+t M z Ya " 4. it .1:,:,y i xr ' 3.pC� §['' ��a � a ) r A^ > a Fit ' �N:�n gg',ea. .i �{, ,� 4,sa ;§.y'r' a D s a s u " ._'. �::.7_ u ^,. r. ..€:, 4 a. ,L .. :.: :, x a =t! to .::. Inappropriate Sexual Behavior 0 ❑ 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ 0 Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ 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 ❑ 11/2 ❑ 2 ❑ 2'h ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 1P� `tea A' 'k 1 •s • o-' tY: ` #''h „yr • iE•At • Age 0-10...$16.32/day ($496/month) County Basic } Age 11-14...$18.05/day ($549/month) Maintenance Y`t Rate Aqe 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 112 On +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 #11wev +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 112 Auu +$.66 Respite Care Total Rate=($30.25 day/$920 month) 4110 $32.88 3 *54',f4 +$.66 Respite Care • Total Rate=($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care OR Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care trill Total Rate=($40.11 day/$1220 month) Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rateint 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 Bo, d WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN Lt � ERVICES . By '1�s 1✓. i !!! ./.%• ,�f1k. � '�� ' �1 _ .� .. / , -,t✓ Deput.'lerk to the Boa 4$4 ,�� Chair S_nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Rush, Phillip and Shannon OF HUMAN SERVICES 2540 S Flanders Ct. Aurora, CO 80013 �_�� By: By: OtiAl-y Di ector �/ By: 9 Weld County Addendum to the CWS-7A I,WS-/A(KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENI011 +IUL 1 tit ,9P710 so 1. THIS CONTRACT AND AGREEMENT, made this date, O11ji 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, Schnitzer, Daniel and Daniela, Provider ID# 1557738, 3519 S. Cathay St, Aurora CO 80013, 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 Q?®J/-6,29q3 LWS-/A(KIU-IU/V9) 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/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 notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County C rk to the B WELD COUNTY BOARD OF SOCIAL '6474 al SERVICES, ON BEHALF OF THE WELD Jf jCOUNTY DEPARTMENT OF HUMAN ERVIC S By. A h/ De Clerk to the Boa a Chair Signa re AUG 1 2011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Schnitzer, Daniel and Daniela OF HUMAN SERVICES 3519 S. Cathay St Aurora CO 80013 By: By. ' i^ JCIA`v'1/4L(- i ector I By: it\a c(1G1�, 3 • • WELD COUNTY ADDENDUM tt To that certain Individual Provider Contract for Puri§ C e Services and Foster Care Facility Agreement (the "Agreement") betty nl SO Schnitzer, Daniel and Daniela and the Weld County Department of Human Services for the period from July 1,2011 through June 30, 2012. • The following provisions, made this \1 day of \J` , 2011, are added to the referenced Agreement. Except as modified hereby, all terms ofthe 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#1557738. 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(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 ❑1'/,)2 round trips a week ❑2) 3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week ❑3'/)7 round trips or more 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 ❑I''/)Two times month O2)Three times a month O2%)Once a week O3)Two times a week O3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a '/:hour per day ❑1%)'%hour a day O2) 1 hour a day O2 %) 1'%-2 hours per day O3)2'/:-3 hours per day O3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed 01) Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week O3%)21 or more hours per week 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.) ❑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. 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 ❑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/intensit of conditions which create the need for services that a..1 to this child. f i ATMs " fit L Sti! ;r wcti:e%°.;s:r4:;°.'am ? y a':,1-1:1 w f., R + i : , k •;'•..y.',.--$1,•'.." ,. #e - * 1 2Y,$}i . ,}9..v.„ed,, ,. ..z;- . ...:..,, :.a. '1-:::,:3•1::, a s .s ' k ' i'-.ak �gnW ' +aTn+`n5F*'i . i "1' d% X ' 5y'h ..";!..:::::::;.:Ell: q Sq 'k 'e'a`rt' s'* i a i.,-:-Iii, k x s ^%' t`.,1 to r is q., ,,£ ti !, a• �. F ' 7t,Is r14<t . a• ''t. .: .,a.1r' .sairo"..r`mx'r 'w` urZ`',..Y.',•1‘4,',,. . " .. - ,I;a *`9 : rsk: Aggression/Cruelty to Animals ❑ O O ❑ O O O Verbal or Physical Threatening O O ❑ O O O O Destructive of Property/Fire Setting O O O O O O O Stealing ❑ O O O O O O Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ O O O O O O Presence of Psychiatric Symptoms/Conditions O O O O O O O Enuresis/Encopresis ❑ ❑ ❑ ❑ O O O Runaway ❑ ❑ O O O O O Sexual Offenses ❑ ❑ O O O O O 6 Weld County Addendum to the C W S-7P (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..1 to this child. ' Y c ik tW.F x x> fit " * ' : ."-:("."-f.'":,' S=* t x�l $' a .. a ",� 111111 ;eflei h fh 4: ate ' "$ kn &@", k .. I * X41 y Yr- J. ;,'e ttit s.zsr w.w�4�x4w s } ..,, ':.sue ~i ,Ydu:. ...;1ax.•-n , . d h a511C:rx. k"Aa"WR% 4 ₹ Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ O O O O O O Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ o Medical Needs (If condition is rated"severe", ❑ O O ❑ O O O please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ O ❑ ❑ ❑ Eating Problems ❑ ❑ 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 ❑ 11/2 ❑ 2 ❑ 2%2 ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE xse kT r' Age 0-10...$16.32/day ($496/month) County Basic t't Age 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 y +$.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 gikK 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)CAI $36.16 3 1/2 tItV. +$.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) Rats 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 Count Clerk to the Board WELD COUNTY BOARD OF SOCIAL ate' SERVICES, ON BEHALF OF THE WELD � � COUNTY DEPARTMENT OF HUMAN 1N42SERVICES 1t61 AL.Ltl� ��4 By:�I✓/ /,/ i , �� i...��:� M JUG Deput lerk to the_ \ Chai 'gnature ••► AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Schnitzer, Daniel and Daniela OF HUMAN SERVICES 3519 S. Cathay St Aurora CO 80013 ` 1 � By: By: �: ()Anl-✓ Dire for By: T-1 t 1 1n1 ca- 9 Weld County Addendum to the CWS-7A L W S-/A(K 10-10/99) 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, Serna, Leo and Carol, Provider ID# 1597453, 1020 Cottonwood 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 LWS-/A(KIU-IU/99) .11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 I:WS-/A(KIU-IV/99) A. 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 CI-rk to the ? WELD COUNTY BOARD OF SOCIAL "?:�� SERVICES, ON BEHALF OF THE WELD • * COUNTY DEPARTMENT OF HUMAN aY!3�11%SERVI ES BY /il //. ^s �i,%I/S� ��/% )► �v,, I A 1-( Depu ; lerk to the Bo Chair S' nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Serna, Leo and Carol OF HUMAN SERVICES 1020 Cottonwood Dr Windsor, CO 80550 By: By: Di ctor �f By: CaJ Q) 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Serna, Leo and Carol 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 4.41 , 2011, are added to the referenced Agreement. Except as modified hereby, all terms of the Areement 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#1597453. 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. (R)//4,94/3 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 I. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1'/:)2 round trips a week ❑2)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week 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 011/2)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 01)Less than a '/1 hour per day 011/2)'A hour a day ❑2) 1 hour a day 02 %) 1'/,-2 hours per day 03)2'/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 ❑2'A) 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 aee appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week 02)8 to 10 hours per week 02%) I I 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. ❑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? 00)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month 03)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Example only do not complete) (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..I to this child. :. -cv„x"ry* r .., A" `iC;;;1'4„' r•v 7 t 2 to „fiky, y"„i$a °t x ' ; "$ ro $'t u w v y s t; t o e F -4 'z`k zxen a • Y t i - f '1,:'" '..,;,•?;.-.0;41;7*. �-p 3 v ,tx r�'^ Y. s ac7.4. !is'{d"•t ��^aaa+ it ”:"*}.r im D l ‘'..c 4 1,1 4-" y•r.?,� a k �,r '_ .,.. `v w ., . .. , ... Su „ ...� . < ..r ., k'�' r.i v xyv^`�ry t.»o-». .. a � v � ..::�.a �.',,ry il ti ;".:iriiiiiii Aggression/Cruelty to Animals ❑ O O ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ O O ❑ O O ❑ Destructive of Property/Fire Setting 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 ❑ Enuresis/Encopresis ❑ ❑ O O O O O Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ 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/intensit of conditions which create the need for services that a..l to this ch x Y 5 a k r 4R , 5 4 s,r. a a; t ild.4 °sue b w`'a '4',4;Itr��. .' a" .'' }3^ 1.:1!.[,<-!,:!!!- ..0 . --!- '..F,* . ... .apt 'x&s a !4.4.' ;;;;',';;;,;1"4a$4613.-S„ ';t;;d J t ;3 + i ti} p i 3.. + L$ H y m}.,ixis:-,1 4j s,, Y yep d r� d ,G s § ;:•! § y° Y•k § s i y � a� '" ., + t';''' ,.7 r9 a.. m° g.c+ '„,:!',;0; t e:sti t'*d, r +' . § a ' �,•,4 a 'Y Nf!' ,rv?4 k . L a$ !IC hfi kZ�Av, t $ « ,w„vt, , s!!S . . ..C..!;!1,;:,%/:- v ",' , < nm':.s�.a..a'I i ...i&ix& i�:.l' .. .. _ . .s..1''v t+.bi'4,141,0:113492,,!, Inappropriate Sexual 0 0 0 0 0 0 0 Behavior Disruptive Behavior ❑ O O O O O O Delinquent Behavior ❑ ❑ ❑ ❑ O O ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ 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 O Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ O Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ O O O O O O Involvement with Child's Family O O O ❑ O O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ID 2'/z ID 3 ❑ 31/4 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE sa' t r x x d- s^'?;' r� s c.a d4v a c s,,* jS�4'�r� Y y.y ,� 4 43.rtt g4, .f'3i� '`v`"'y-w `k≥ b' ,. E r.� a1`� s yy Fie sw ssks�*'' rcra'� `y k r,` za itA 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) $23.01 1 112 +$.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 ezi 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 if $30.25 day/$920 month(Includes Respite) Rate 4,74 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 v I. COUNTY DEPARTMENT OF HUMAN SERVICES 1861 ('` • BY l .L i/. !.�li'. , � - A / w Deput Jerk to the Chair i ature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Sena, Leo and Carol OF HUMAN SERVICES 1020 Cottonwood Dr Windsor, CO 80550 By: By: ector By: Reil- 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, 7'3 '// , y a�d between the Board of Weld County Commissioners, sitting as the Board of Social 1S icJU-otS ehWIf a 58 the Weld County Department of Human Services, hereinafter called "County Department" and, Sevestre, Lewis and Maureen, Provider ID# 1551169, 1717 69th Ave, 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 W S-/A(K I U-I U/99) .11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 L W J-/A(K IU-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 -rk to ...j La WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN 1%6t. � SERVICES• 14 1-s By Dep fCle to the Bo Chair Sign ure AUG 1 2011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Sevestre, Lewis and Maureen OF HUMAN SERVICES 1717 69th Ave Greeley, CO 80634 By: By: ctor j I By: 74�_ 3 O?t7ii aay.3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Sevestre, Lewis and Maureen and the Weld County Department of Human Services for the period from July 1, 2011 through June 30, 2012. The following provisions, made this t3 day of , 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#1551169. 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 (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 ❑1'/:)2 round trips a week ❑2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week ❑3%)7 round trips or more 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 O2)Three times a month ❑2''%)Once a week O3)Two times a week O3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a%hour per day ❑1%) '/,hour a day ❑2) 1 hour a day O2 %) 1'/r2 hours per day O3)2'h-3 hours per day O3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/:) II to 14 hours per week ❑3)Constant basis during awake hours O3%)Nighttime hours Comments: _ P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/)5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week 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. ❑1'/i)Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. 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 (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'4 d,k= f a z I r z nt lam i 4:44. i' fi }p�g� a,+a" ,i rs..ba� .. ... .. ...: .. ..-r ..wn'5'i' =x .L..,.w=.: .. ,".«, . Aggression/Cruelty to Animals ❑ ❑ ❑ 0 0 ❑ ❑ Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ 0 0 0 0 0 Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions 0 ❑ ❑ 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ 0 0 Runaway ❑ ❑ 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child.044;5kA <.:. t.if n&x. .n.... ..t.u. e i axtre— vRs°rv� _ . .. .' . . .i `: .iv$ `r&'h2^1,4 r .. ..... ..ix SrM1}R. Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ O ❑ O O Medical Needs (If condition is rated"severe", ❑ ❑ ❑ O O O O please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ O O O O O Boundary Issues ❑ ❑ ❑ O ❑ O O Requires Night Care ❑ O 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 ❑ 11/2 ❑ 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� a3S .3.,�k� 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 $586/month +Res.ite Care$.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) ites $29.59 2 112 4.66 Respite Care 41. Total Rate=($30.25 day/$920 month) $32.88 3 4.66 Respite Care Total Rate=($33.54day/$1020 month) *211 $36.16 3 1/2 +$.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 ,51 $30.25 day/$920 month(Includes Respite) Rate wag Effective 7/1/2008 8 Weld County Addendum to the CWS-7A t , IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the B WELD COUNTY BOARD OF SOCIAL c,LSERVICES, ON BEHALF OF THE WELD OUNTY DEPARTMENT OF HUMAN RVICES S 1861 �� By://4-4,4,d 14,d , �� Deput Jerk to the Boaz ,' ( 1` Chair gnature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Sevestre, Lewis and Maureen OF HUMAN SERVICES 1717 69th Ave Greeley, CO 80634 By: By: Dir ctor By: 9 Weld County Addendum to the CWS-7A I,WD-/A (KIU-10/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES v, AND FOYER CARE FACILITY AGREEMENT 1. THIS CONTr*ACT AND AGREEMENT, made this date, 7 ///// by and between the Board f Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld-County Department of Human Services, hereinafter called"County Department" and, Shindle, Danny and Andrea, Provider ID#1550177, 1561 41st Ave Ct, Greeley, CO 80634- 2758, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 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 c9o//-c 3 LWJ-/AtKIU-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-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 B WELD COUNTY BOARD OF SOCIAL �r .E�j SERVICES, ON BEHALF OF THE WELD / OUNTY DEPARTMENT OF HUMAN A :r RVICES IW By / l/ ithur , Depu ler c to the Boar Chair Sig ture Approval as to Substance: PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Shindle, Danny and Andrea OF HUMAN SERVICES 1561 41st Ave Ct Greeley, CO 80634-2758 By: 1 By: � Dir ctor By: � O� 3 c WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Shindle, Danny and Andrea and the Weld County Department of Human Services for the period from July 1, 2011 through June 30, 2012. The following provisions, made this I day of iT , 2011, are added to the referenced Agreement. Except as modified hereby, all terms of the A reement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1550177. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided,the County reserves the right to deny payment. B. Be submitted by the 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 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 (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 • (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 On One round trip a week ❑1'/z)2 round trips a week ❑2)3-4 round trips a week. O2%) 5 round trips a week O3)6 round trips a week ❑3'/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 ❑1)Once a month ❑1'/)Two times month O2)Three times a month ❑2%z)Once a week O3)Two times a week ❑3%z)Three times a week or more 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''/2 hour per day ❑1%)'/2 hour a day O2) 1 hour a day O2 %) I'A-2 hours per day O3)2'A-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 O2%) 11 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 age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week O2)8 to 10 hours per week O2%) I I to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑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. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. ❑3%z)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 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-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that al DI to this child. .o-te� *xa+�hi" + t t 4 pry " s. k ,1.2,, &S P f �#, v" "N "1 z3141 w *eAe ' r . ��' *4 t ge it r s.. r,a' --;,1-"-,-;;-'2::=7":x -;;. ';;'..e=!-",-4. it '7.7 n•' {rya n *"v ce} q .n L4`. 4 4 'N g S k ,� ia9, v y" ' 44'4.474;5,—,',.i...kfi '• w : . w§$rde'u t v . : ' .. r:' .., „„'i! "� :.... °ex4wCxN'v. A;3. lr ikl Aggression/Cruelty to Animals ❑ 0 0 0 0 0 0 Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ 0 0 Runaway ❑ ❑ ❑ ❑ 0 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. 11.4,4:147,1:215:1;;%::';) 4t t y y��+x _ �c-a n S 3'w w _ k.. .r x n x x a , • � ` § a�yr, : m, :ti ^ vw�'�"'�°^ x � t #"c�i . F-S'x 5 z4. .ct. '�'� r s 7 c. ,:. a+Y ,..a - �aaa twti' e t S°a $s fa ,�., r+a m"A.+.}�.??��' ' i § t ' uvx ^ v M - , s a €szfk1.''� ,`a xe : 1 „s ,}b'ua '&401,...::1:::',rrz tr 7:',..;..- +a - {""fie", 5, `! f c. �f2+a�' s 's v S +. s•:::-;;;',442,-, ,e... a :y-% �- a - i� �`igA4• ab �p,1. _'A_#a.:., .,4. `a's ^x, , ....+�. , .:, t,dam.,,,r.s. . .Y. :' • 46#4i4'e. .... ,a..ax...�.a.....,.b... '% °.'§'.v. .`�'*sroa?o .i Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ O O O O Depressive-like Behavior ❑ O O O O O O Medical Needs (If condition is rated"severe-, ❑ ❑ ❑ ❑ O ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ O O O O O Eating Problems ❑ ❑ O O O O O Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ O 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 Ill 11/2 Ill2 El2%z Ill3 ❑ 3%2 7 Weld County Addendum to the CWS (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE A.e 0-10...$16.32/da $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) $26.30 LAA:2 +$.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) $36.16 3 1/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down ($+$ 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 th WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES It\ By: Al 791-0 Deput lerk to the Bo � � Chair Sig ature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Shindle, Danny and Andrea OF HUMAN SERVICES 1561 41st Ave Ct Greeley, CO 80634-2758 By: y -4> Di ctor By: oi20/A-a7c7g0 9 Weld County Addendum to the CWS-7A LWS-/A(KIu-Iu/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7///1/ 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, Skeldum, William, Provider ID# 16666, 5113 Saguaro Ct, Johnstown, CO 80534, hereinafter called "Provider." 2. This Contract and Agreement shalt 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 Seres. 6. To keep confidential the information shared about the child and his/her family. J 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. o toti 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 Tor/day; LWS-/AIKIU-IU/99) • {1t 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 B.- : n.r WELD COUNTY BOARD OF SOCIAL 41 Ea Las. SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN e StERVICES 1861 .:kb By: I ii /./. i , 47A ,/ w .A I=tO� Dept' Clerk tot e Boa`s j r Chair Sign aure Approval as to Substance: PROVIDER AUG 1 7 2011 WELD COUNTY DEPARTMENT Skeldum, William OF HUMAN SERVICES 5113 Saguaro Ct Johnstown, CO 80534 p By:_ X . C/� . r )ofp By: /J,v /1 lu R/� Di,ector By. 3 (2C7 c//07GX 4/3 t WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Skeldum, William 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 day of 0- , 2011, are added to the referenced Agreement. Except as modified hereby, all terms of the A 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#16666. 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 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 DI)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 ❑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 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 ''/x hour per day 01%) 1/2 hour a day ❑2) 1 hour a day 02 '/:) 1'/r2 hours per day 03)2'/2-3 hours per day ❑3%:)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 14 hours per week ❑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.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 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) DI) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (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 I to this child. t ry amts s x ws'l a N'° -. t 4 . x4 x rm' n� t 1 P. } x 1:27'" it " �.(. a,xa v r c . x 7" „3 j e: x '....r::'''..- *Y°'* i v . wa:;� i c ' a- '� ` s i ka :r `* ,',..a�..aa. . ,a--' ;---.----0",---a :xio-"4 - �..,' /-. +. .,"}.a i-h S.. .iln^e..+t u+.Nfias.§ fe.t 44'." Y` ... ! inr } Aggression/Cruelty to Animals ❑ 0 0 ❑ 0 0 0 Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ 0 0 0 0 0 Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ 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 a..1 to this child. 'y, PSdf $ t ,. Y t k ...yeti' Q drikr,*[,4 5 A'} .F'M4 8 y` rd, a $4 .. t t _• fir? `I .i i* i ` —it `* s f' .s,''zy „r� t s 5 ;lit v z xr .a .d d r '. Y>E� I,y '2 t • „3$ e s'11, .:' +L ,` _ .,.k .,r.I;.:1"1, .. . . ? ..> '"„...'. . .,.", t » .' .: -3 k ., , .4t ' .t.:.., •F. F�4�,�.�,..v.a..,.°' 'o-" .)., am+ 4 :tt•a Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ El please complete the Medically fragile NBC) Emancipation ❑ 0 0 ❑ 0 0 0 Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ ❑ ❑ 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 ❑l ❑ 1'/ ❑ 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 z s a , ,., I� �4ia#�:r4w �#: A•e0-10...$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) nos $23.01 1 1/2 +$.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 4.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 4.66 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) Rate34 gl 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 tot ;� WELD COUNTY BOARD OF SOCIAL #4 ELI SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN 'SERVICES 1861 tcalj .� By: /./. 14 ;sW� A, f, .! Deput' ler to the Boa 1� � Chair S. nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Skeldum, William OF HUMAN SERVICES 5113 Saguaro Ct Johnstown, CO 80534 n,/ By: By: l VN� gC� ector By: 9 Weld County Addendum to the CWS-7A 1. 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, /. /I 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, Spahr, Mary Ellen, Provider ID#72929, 144 50th Ave, 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 LWS-/A tKIU-1U/991 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/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 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 Cou •lerk to the car.■ WELD COUNTY BOARD OF SOCIAL i Lam• La SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN % SERVICES By: I :///.� i sC/%1;� �j�>I�� /L (!1, Deput P lerk to the :4i� ` \ ► Chair Si nature Approval as to Substance: " PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Spahr, Mary Ellen OF HUMAN SERVICES 144 50th Ave Greeley, CO 80634 By: By: L- G� Dir for By: 3 &C//-aay_ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Spahr, Mary Ellen 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 day of Owl , 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#72929. 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. air/Aa � 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, and03 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, m,king false statements, or receiving stolen property; ..______?7{, // 3 eld County Ad endum 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'/i)2 round trips a week ❑2)3-4 round trips a week. ❑2''/)5 round trips a week 03)6 round trips a week ❑3''/)7 round trips or more Coln ments: 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 ❑2)Three times a month 02%)Once a week 03)Two times a week 031/2)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''/I hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 %) 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 ❑I) 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 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/2) I 1 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.) DI) Face-to-face contact one time per month with child and minimal crisis intervention. Di%n)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? 00)Not needed or provided by another source(i.e. Medicaid) DI)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (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. +" �.. 5 r �-n t this ‘-::',•!;".,.„....1....--' -'' ' d ."h"AT...".t'e a''" V •� h h } 1 b h r i� 4 Lk.5$ ri Y ¢ $ a . .:e'• t.px .: 7 • yx 5't ° .1"� w s'tn M t qi 4 r{ H y y 41 t i u�3. - z i -' 3 t fl w *s7 s+ ae '� ,'..w�� sa;: ._ r::. ., �.,.. 'A. : ..3'.,. o-t ix.r<.. , e,-I.vw.a. ' a.'w"n�a: .�,. '4 m �`�v .c4... Aggression/Cruelty to Animals ❑ 0 0 ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ 0 0 ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 ❑ Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ 0 Runaway ❑ ❑ ❑ 0 ❑ 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7A (Example only do not complete) (Exhibit B) WELD COUNTY OHS NEEDS BASED CARE • BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. r:�3k 3 m, n e '••'"'";"'• 1.''').17,1:!';':,:.:-. x t''.A " x �` •.-':•' ry � y A k fi `%w '''•••"."1/4&•4,.."!4":)';'':: {.4 '' ) Iig `x:vv i 4� `';,y N1 y. - i 5 `4#.sue' s.t• :c. "^ .ra.`.,' }r ' ,u . r .. .� ' 3y'a s41::::r 77; „; l�.i a ;;f,r,'. * ,x ca t ,i '' a,1."75r v ,. t a 4 . k:: rf ':w °+x. m. ix ti< # ew r � .:'xTY4w"w :„. x"4Fi, r -2 ' a i +' fp s '}S"�. .,y,x ::yry § ,. # T m;,v if"R P '-;:44., �` m ' :taAi..^+v i r yt; 4 4 r' c�'a.a,a z .... '.' '" .,,?,... , . . 9 ...^. ', PhM'C.' .Ch�': �9Mx �uC.ev.x�.... a i "v�+ .�"s � fi'c 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", ❑ O El O O O O please complete the Medically fragile NBC) Emancipation ❑ O O O O O O Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ O O O O ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 Ell ❑ 1'/z ❑ 2 Ill2%z ❑ 3 ❑ 3'V2 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE r nmxa�'•*��' �" -q'- s€ep sEx' ^am *r`bn� �xr �4 � 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 $586/month r, +Res•ite Care$.66/da $20/month ;ttr $19.73 1 +$.66 Respite Care .14 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) 411 01 $29.59 2 1/2 44 +$.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) AssessmenUEmergency it..14 $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 1< .L JL %COUNTY DEPARTMENT OF HUMAN ERVICES By: L/4,,J, d' ?a Dili`. �y: /(//i -4 -ic., Deputy %erk to the Boa�� J ll Chair Si: ature AUG 1 720°! Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Spahr, Mary Ellen OF HUMAN SERVICES 144 50th Ave Greeley, CO 80634 By: By: G/1 Direr or By: O2C/aa5'3 9 Weld County Addendum to the CWS-7A lAPs/J-/A(KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMRAI lull JUL 19 An 9 56 1. THIS CONTRACT AND AGREEMENT, made this date, t.t4 1A "J ,c2(jI I by and between the Board of Weld County Commissioners, sitting as the Board of Sbcial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Steele, Dana and Cassandra, Provider ID# 1551234, 324 Fossil Dr., Johnstown, CO 80534, 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 LWJ-/A(KIU-IU/99) 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-IU/YY) 41 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 ;•� j(%/%q� WELD COUD ()OFF .4U %SERVICES, ONNTY BEHALFBOAR OFF THESCIAL WELD �� OUNTY DEPARTMENT OF HUMAN • ERVICES 11.61 By: �.ii/ /./_ i. �� %�%�.l�i� i AA lip Dep u.: lerk to the Boar. (II 1i Chair Sig ature �rr.r+�►� AUG 1 7 011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Steele, Dana and Cassandra OF HUMAN SERVICES 324 Fossil Dr. Johnstown, CO 80534 By: 1\1).0 By: /) z'7�- 1z. rector By: / / • _- ---• 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose oillisjilt 1:215e Services and Foster Care Facility Agreement(the"Agreement") between An 9 ss Steele, Dana and Cassandra 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 ,) t..Qn , 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#1551234. 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. I 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 ❑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 ❑I)Once a month ❑1'/)Two times month ❑2)Three times a month ❑2''/)Once a week 03)Two times a week ❑3/)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements Do Less than a'/:hour per day 01%) 1/2 hour a day 02) I hour a day 02 V2) 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? ❑ 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 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'/a)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. 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. ❑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%) 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) DI) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (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. F ' 'rs' s � } . 3. T t S n'e 'i'iyt 4 i t':` ^S h k "'e4 Yh a � � e L; ." ...d: t ..C. n . ,"}, <'4: :.rdnr .a ....,.-71+. eaw ua a - 'a � ��r "�d".': ham" arse fl ays, -,t,;';'r.:,,N� a�. k e - •.x.,.₹a .. d ly s:fi {{L �x'+ ,.,�:a u mf"x:�'+'°,5, ..., . .. i_c....uws M0I.tvteX aiix�uxm_ ... ... < ..v vrnX° e:.C.� "e..L. s£553 em.iS.rcai"L§ Aggression/Cruelty to Animals ❑ ❑ 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 Self-injurious Behavior ❑ ❑ 0 0 ❑ 0 0 Substance Abuse ❑ ❑ ❑ 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 rate the behavior/intensit of conditions which create the need for services that a..1 to this child. 9 YCe� ''! l 5:"a Please st t ( J. ifli i' t,v f F *4. 4 y.^x,:„:44 „,...„,04. P_'x'F f$sy t te `�' au . ''''''7:::J/:;;;CI ₹.3 ₹g - d ... "t ` r„r,::. v�S , 'A+ 4 " E i .17.`"e",' d 1;i ::,:!r'y "Tee " A u *'P Ss •'S. a • ':,,,A,,"-. ..• '4...i.::•re° -v 'rfll t .. ,.e { b 4 i-I'''''' . 4 . k. i inn t er • ay Ai :1 1- .,. �t .gsko�`:4. -r .t t' ..- . t, .. 3. . I. r,.l naa L•, . . . e �'�,"+ . °'u 4 ,..,.as v.: .v.,f„ _ . .. . ix_.xuy,...syi'.- .w 'e. Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 please complete the Medically fragile NBC) Emancipation ❑ O O O O O ❑ Eating Problems ❑ O O O O O O Boundary Issues ❑ ❑ ❑ ❑ ❑ O O Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 El 11/2 ❑ 2 El 21/4 ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ac �� a t e yea�^�x'fi t11.� t'*• f x�a ;,; � A � R£ °'>� y.:g y �, i" ��"k�tr� �e ,a s•# s1�xr'xi a# �(} '�" 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 irjgg $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 r +$.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) $36.16 3 1/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care WW 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 SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES 1861By �� .� �.� .: Ai4tt,% Depu , lerk to the f,f5 Chair ignature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Steele, Dana and Cassandra OF HUMAN SERVICES 324 Fossil Dr. Johnstown, CO 80534 J By: BY: ( Dire for By: / - / aD//- 070293 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-IU/99) t INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMEMI JUL is Leifin 101 S 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, Steitz, Daniel and Natalie, Provider ID# 1546930, 1701 Elder Ave, 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-IA 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 I:WJ-/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 Count -rk to the B•- t- / 1 WELD COUNTY BOARD OF SOCIAL • RVICES, ON BEHALF OF THE WELD L - S't UNTY DEPARTMENT OF HUMAN • s I � i VICES Deputy? rk to the Board _ Chair Sig ature Approval as to Substance: PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Steitz, Daniel and Natalie OF HUMAN SERVICES 1701 Elder Ave Greeley, CO 80631 By: By: Cl rector By: "1 3 WELD COUNTY ADDENDUM' j" 5 817 10 is To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Steitz, Daniel and Natalie and the Weld County Department of Human Services for the period from July 1, 2011 through June 30, 2012. The following provisions, made this 1 day of , 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#1546930. 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. alp/i_(20? 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 01)One round trip a week ❑1%)2 round trips a week ❑2)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week ❑3%:)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month ❑1'/:)Two times month ❑2)Three times a month ❑2%)Once a week 03)Two times a week ❑3'/)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a ''/hour per day 01%) 1/2 hour a day 02) I hour a day 02 %) 1'h-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 ❑2%) I 1 to 14 hours per week ❑3)Constant basis during awake hours ❑3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? O Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week 02)8 to I0 hours per week ❑2' ) 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.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1''/) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%)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) 01)Less than 4 hours per month ❑2)4-8 hours per month 03)9-12 hours per month 5 Weld County Addendum to the CWS-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. '+ .,yamr ' t. • • • ".• 4 . d , ; r:• y§'t..Sr. ge N S ..,e: ,fi=t .- :. 4"4 x.aa.+.m 1 a .- - •— .,, s t r cA. y� x ,� ..4:1„y TT��' k ,gayS u� t ,":;.11...i.1:..., k �➢" t yisx ka5 „ : °`{, a w ay.X �'�tw .0,EC r )t tl 21..:;. 4w '' :';I:c,4"fir" § k. ,.. , +k... +. ' + !'t.11".:.12,...,•;,?"..s' .� s. s, fw"'C?ii y4�a % p,� . 7'` r F� mow.x� r'„rs:; .4`" . l eEC,.h . .,:"', .m +`�h�;te .��; '�+.» • ...�,..,._ ."# '`-`= � : '°`,''s'. , tI: Aggression/Cruelty to Animals ❑ O O O O O O Verbal or Physical Threatening O O O O O O O Destructive of Property/Fire Setting O O O O O O O Stealing ❑ ❑ O O ❑ O O Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ O ❑ ❑ O O O Enuresis/Encopresis ❑ O O O O O O Runaway ❑ ❑ ❑ 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 ar rl to this child. t y�y'y{R5�;}( . 3�. 'ypgy,^{na€z,ys a F r to t F+;aS }. k.a �y(yTy'TW i� #- 514 4' M_•. f } ��:81-2)„",,,,,,-- 1.2)„ ,,,,-- ,,,„ 'e..G Ml ,n � 'ate .. ��" j _ *.� art § v n arryt xu � ate`` v,-:.:Ic , .a' r-i.-a. .: :: ri $ 'S dT'> t*€ '' ° i,". w— g wa a ' t sd x �¢ 5 rok nH LY"..�� t �P�4.v"� 4y fir 5 __ ., .. .P 4kW 'a4k7 - saa 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ 0 0 Boundary Issues ❑ ❑ ❑ 0 ❑ 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%2 ❑ 2 ❑ 2'/s ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE q� i eat Twv sd Pr� y x 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 ($586/month) +Respite Care$.66/day ($20/month) $19.73 4.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 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 4.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 4.66 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) Ikc 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 Q°� COUNTY DEPARTMENT OF HUMAN ERVICES n61 ' 1 ' By: ( h/ Deputy erk to the Boa j Chair S'gnature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Steitz, Daniel and Natalie OF HUMAN SERVICES 1701 Elder Ave Greeley, CO 80631 By By: D ector By: _ � 9 Weld County Addendum to the CWS-7A (-WS-/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, J at r 5, a O /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, Van Den Elzen, Dawn, Provider ID#44282, 5819 W 16th St Ln, 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 C// ft? L W J-/A(K I U-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-111/99) 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 ' •)_* WELD COUNTY BOARD OF SOCIAL J SERVICES, ON BEHALF OF THE WELD ' , N OUNTY EPARTMENT OF HUMAN ERVICES 1161 By: IB Deput t Jerk to the Boar. �� Fy Bt Chair Sign to mG 1 2011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Van Den Elzen, Dawn OF HUMAN SERVICES 5819 W 16th St Ln Greeley, CO 80634 By: By: z - Dir ctor By: 3 //- 4/j WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Van Den Elzen, Dawn and the Weld County Department of Human Services for the period from July 1,2011 through June 30,2012. The following provisions, made this F day of ,Tu<y , 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#44282. 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 ❑1)One round trip a week O1%)2 round trips a week ❑2)3-4 round trips a week. ❑2'/)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? O Basic Maint.)No participation required ❑1)Once a month ❑1'/z)Two times month O2)Three times a month O2%)Once a week O3)Two times a week O3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a'/:hour per day 01%) 'A hour a day O2) 1 hour a day O2 /) 1'/r2 hours per day O3)2'A-3 hours per day O 3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week O1%)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3/)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond ase appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week O2)8 to I 0 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 I. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two timesper month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3)Face-to-face contact weekly with child and occasional crisis intervention. ❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 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..l to this child. " �4'"w �� s" :� ., a rots ` 3 ,,_a 'Nt,�`�'' x'�' t� "'rs � a�r SSrvtx'i S T ..A '.t.;::',:o...,,{ t` IM N Ya Gku kdh ask' atatn`'d� 4. �1 a , f r& r t -4a F ..7.}t'1 �r v4 4-1,±-...,,,,%.::. ± r ;xx-ti a, . d +2 �,a b., x rte t Y, .a �, y ': : rv. :....."'.. %:rs M.%x. b.r .. r... k d�iA. *wx'd95 r.�'"....lii..v ..5. x. .. .t.Av e?'•" c:: ... .. . a Aggression/Cruelty to Animals ❑ 0 0 0 0 0 0 Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 ❑ 0 0 0 0 Substance Abuse ❑ ❑ ❑ 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 ❑ 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..I to this child. a -,q sm:, " . � ' ms':."°l!':°$q� n ``!, '�e �:'' �.^'`_k �+- t ; '." its rs er* s of h s k � u,r' 'ca - ` ' t i r aa '7 z� s -,,,,‘,„.:::-.?4,11,-,;,,,,,_s '€mss„,; t" gs '` 4 o- +4 r s '+ s o- - 4rtr; . .,. , a��:�.��iFsro" .4,-..4.:./., ,a= .n ' . ..,r � +.��'`� e '....,c.,. .:. �. , .., .... r ,.'M ...�.., a� wi 9�� _x��", e. !. Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", 0 ❑ ❑ ❑ 0 ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 0 01 0 1'h ❑ 2 ❑ 2% ❑ 3 ❑ 3'h 7 Weld County Addendum to the CWS-7A S-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE a_n A.e 0-10...$16.32/da $496/month County Basic A.e 11-14...$18.05/da $549/month Maintenance ,yy 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) $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) t $26.30 2 trish +$.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) tlt $32.88 3 • +$,66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3112 fects +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) Spiaj 4ttl $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency $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 WELD ! ,/)WitCOUNTY DEPARTMENT OF HUMAN RVICES By L�h. 1 /,� .t J �.�% • / ! / (, Deput er to the Boa Chair Signature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Van Den Elzen, Dawn OF HUMAN SERVICES 5819 W 16th St Ln Greeley, CO 80634 By: By: /?aa'- (1zey_ ector By: 07.0/7-07x8 9 Weld County Addendum to the CWS-7A CWS-/A (KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT i 1. THIS CONTRACT AND AGREEMENT, made this date, 7/t'/I I by and4li(eep the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf-81/4 the Weld County Department of Human Services, hereinafter called"County Department" and, Vincent, Jessica and Ryan, Provider ID# 1587461, 4910 W 2nd Street, Greeley, CO 80654, 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 cQ0//-c7c2 f,3 CWS-/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 UN/S-/A(K I U-l 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 r' 1 WELD COUNTY BOARD OF SOCIAL 'i SERVICES, ON BEHALF OF THE WELD ,COUNTY DEPARTMENT OF HUMAN bc11/42 .ERVICES By: ;�i%d,L ; ►�� . .s�i.,IJ ' �,R 'B ' /tl? 11 I A-1�� Bti/ Depu , lerk to the Boar y.`«�( I n 1 Chair Si nature "`�-►� AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Vincent, Jessica and Ryan OF HUMAN SERVICES 4910 W 2nd Street Greeley, CO 80654 By: By:• U`L> ° ('-Y �✓Vv DI ector By: Atea V 3 cQo//_ )7„ 9,3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Vincent,Jessica and Ryan 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 (tuft , 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#1587461. 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©// ��`f3 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. ❑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? O Basic Maint.)No participation required ❑1)Once a month ❑1'/:)Two times month 02)Three times a month 02%)Once a week ❑3)Two times a week ❑3'/x)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 ''/2 hour per day 01%) 1/2 hour a day 02) I hour a day 02 '/) 1'/,-2 hours per day 03)2'/:-3 hours per day 031/2) 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 02)8 to 10 hours per week 02%) I I to 14 hours per week 0 3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)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 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.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)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. ❑3) 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) 01)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/mtensit of condit•ions which create the need for services that a..1 to this child ..; z.. Ill it '*. 7',.-' - y' - "` m i-'. y„a k -': a r$ "=:= v a-i �'� s..r" �t�� 4rtiYt ,� t „..c � a � � � atiiIr * t 0f r': • g q: , ,..i p.A, -, �# - tt41 yyt1«'t3" ' Is"'�7" b y,_+....y "- In. a r 3 :4'":::?:.4-::..1,-* x i s 1.1: 'ma Ps $ a . s ' `_.. . ' ' r, x. . .E ..4-.,"- #, .::..!-:1-;-:1:;;.. a:.. e$4: ...4. c. : .;6:.n i4",,, :.._... =-;-‘0".°�.�..'- '�. Aggression/Cruelty to Animals O O O O O O O Verbal or Physical Threatening ❑ O O O O O ❑ Destructive of Property/Fire Setting O O O O O O O Stealing ❑ O O O O O O Self-injurious Behavior ❑ ❑ O O O O O Substance Abuse ❑ O O O O O O Presence of Psychiatric Symptoms/Conditions ❑ O O O O O O Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ O O O O Sexual Offenses ❑ O O O O O O 6 Weld County Addendum to the CWS-7A (Example only do not complete) (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..I to this child i }��d gnef 1a�, :'. 2ry ' s°' xm.tar zi "'aK' ' " +v irY �'7'? '+° .. i Ye b 5 T-.4 ,:.' �' 7 5 ; . y. r4 n " s +�Sz'x ' ,:• � al, §t�` '� k. , �i.��, 's {. �,� .a•;;;‘77-1. y fist �, ,.� s b eJ'';‘:4:;'''':•-:?/:--'.'!'" r ., � ._''rs 7,,,,€"t13o� `a` siA„: a y y , ,"u h d. Y �aY ,:':;%...3,-: Y !': 5r 4 1.V�y4 t.1%a' TFtn li - S � F� � � � § t�,�i��z' �," ad'i5 3-s ? p i . y, . 5w gakx P.� * �f,�,,�.„. 3` J 3 "+ - S :::-.;$ iha L4 .tiax .i t a+N;r.444i . xvee 'r .`s. ., ,....,...u ., . „ ... ', .,,;s..:: .a, 'Si75 f ra"« .$.„ P.. . .. . . . v.#_ .t. �§ra�x �, 4' _ ."�}� 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 ❑ Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 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 • ":• . , ttt ; x 3 q tai -3. ' '5 , • t a u ,u [ uu �4 FF.. .�� n 1..: .a�w.=at'��3�.,''. '..��'. (.. � ""�#i{.s`.��.�G;vss TR.'S..�k a�;a •t' Age 0-10...$16.32/day ($496/month) County Basic Yi. 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) Pea $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2VirA +$.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 trig $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`; , WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD ' r s� 4 %, OUNTY DEPARTMENT OF HUMAN (` = ERVICES By: kirle De put to the Boa tR„4 (r Chair S nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Vincent, Jessica and Ryan OF HUMAN SERVICES 4910 W 2nd Street Greeley, CO 80654 By: By: DI ector By: ill /It dO//- aasY3 9 Weld County Addendum to the CWS-7A LWJ-/A tKIU-1U/99) • • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, �ilki l (Ls A t a�dCC'between the Board of Weld County Commissioners, sitting as the Board 10 WT Services, on behalf of the Weld County Department of Human Services, hereinafter called"County Department' and, Wade, Michael and Jodyne, Provider ID# 1554152, 1016 Cottonwood 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 c Ci/-c?a7 .3 UN/S-/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 1:W5-/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 Boar WELD COUNTY BOARD OF SOCIAL S ERVICES, ON BEHALF OF THE WELD•' \ UNTY DEPARTMENT OF HUMAN Sx; VICES F . BY %L ./' �i ��_ . l� /i1 , ) �! /1 ( .w Deput lerk o the Board ♦�I 1 I Chair Sig ature Approval as to Substance: PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Wade, Michael and Jodyne OF HUMAN SERVICES 1016 Cottonwood Dr Windsor, CO 80550 By: ` By:` Dir ctor By: Jtj\--"H‘n/Aar WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Wade, Michael and Jodyne aI jii -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 j day of, )iI LI , 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#1554152. 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 ❑1)One round trip a week 01%)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 ❑l)Once a month 01%)Two times month ❑2)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? 0 Basic Maint.)No educational requirements ❑1)Less than a 'h hour per day 01%) 1/2 hour a day 02) I hour a day 02 %) 1'h-2 hours per day 03)2'/2-3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.)No special involvement needed DI)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 0 3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%)21 or more hours per week 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.) ❑I) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 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 s� Please rate the behavior/intensit of conditions which create the need for services that a..I to this child. Et` „{ zrs .,;::.•`., f -; f . F`is -. . t '^�" {°1,4-4 kY Si it 4 : y y _ '. S �i t .. 2� § # t^i ysi�, vti ar Rs - a3 r s-.W z 7 v t .S r h svS a �"' •v ' F'•3 a 'e xis a" k , Fa;' v•-; t °� t", �: tea . 't� 9 e • ' ' k p3€ ay ,,3 , t .,!.t .:I'F q A ` : Ilitrkitt.' # ,...uay k r ;:' 7•••• .. • `..::,..-A.:1-..:,' �."yi9 {jyy t 1 i Aggression/Cruelty to Animals 0 0 0 0 0 0 0 Verbal or Physical Threatening 0 0 0 ❑ 0 0 ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 ❑ 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ ❑ ❑ ❑ 0 0 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 DNS 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. p Fv i 4 1 A S y x A M R'xA ` �N �ii k i n d y^+4 Y ,,,••;+•7+1,-+i*; 2 '�:�.:,'g4 rrt •" ' l'•' }7P a• • •°� � a"�Y'}�� `x .. �,'::.-. ..s.,:\.s ,: . . .:• ., ._ _� t.?.9' m..e.�t2*.$1u�r�#.f.e"*.,' a,.°..... . . , _.> , ,..,t`*�.''_�'.�+.i4 r..�.:ri�+ars4 �₹, 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", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family 0 0 0 ❑ 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 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 C Vy �1 4. � tfl � t^Fbes'5'g �,eUKht" • 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 4.66 Respite Care Total Rate= ($20.39 day/$620 month) IVA $23.01 1 112 4.66 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 4.66 Respite Care Total Rate=($30.25 day/$920 month) ;4k— $32.88 3 4.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 112 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) ettot 4 $39.45 TRCCF Drop Down 4.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency gtti $30.25 day/$920 month(Includes Respite) Rate ft- Effective 7/1/2008 8 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the : •: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD OUNTY DEPARTMENT OF HUMAN y ' =;ERVICES By '�.r%!///_' 7 .� ��'.� �iv�► �: Ii/l J l/bt/42-- Deputy ' erk to the Boar:�w � 'r Chair Si ature / AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Wade, Michael and Jodyne OF HUMAN SERVICES 1016 Cottonwood Dr Windsor, CO 80550 By: By: rector l By. 40C� c` 9 Weld County Addendum to the CWS-7A L W J-/A(K I U-I U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 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, Walker, Kurt and Jennifer, Provider ID# 1546248, 519 Trout Creek Ct, Windsor, CO 80550- 3194, 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 LWJ-/A(KMU-1U/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) A. 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 i� WELD COUNTY BOARD OF SOCIAL Lam SERVICES, ON BEHALF OF THE WELD . COUNTY DEPARTMENT OF HUMAN ERVIC Ito By: L(�i% a �'�r. :IS�`!��.. B : � , i Deput lerk to the Boat'. A n41C.�� Chair Signat re Approval as to Substance: tU PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT Walker, Kurt and Jennifer OF HUMAN SERVICES 519 Trout Creek Ct Windsor, CO 80550-3194 By: By: [--(1611Q— Dir ctor By: .�L{,.\s,.)4 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Walker, Kurt and Jennifer 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 2011, are added to the referenced Agreement. Except as modified hereby, all terms of the 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#1546248. 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. cg O/7 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 ❑2)3-4 round trips a week. ❑2/) 5 round trips a week 03)6 round trips a week ❑3'/:)7 round trips or more 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 ❑l''/)Two times month ❑2)Three times a month ❑2/)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? ❑ Basic Maint.)No educational requirements ❑1)Less than a ''/z 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? ❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week ❑1'/:)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%:) 11 to 14 hours per week ❑3)Constant basis during awake hours 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 ❑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. ❑l/) 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. ❑3)Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/:) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 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..l to this child. v t` 'r " a F q et K - -.vt't * F 4 � t" 7'`y '' -. t i•,:,1:-.. t 1...-•t •, +- i ddgg,₹;�Fz' i a € dk M r � 0 ri itit : *4.4.11."4.4,4-111' C R L.AMY "C i 994c �� `o s d�.� ��, � I'3 ^^+, M *,...',......),C. 3 . , t A. 4n°i .' '' °y5 -t4 fitfill .#.. 4 . ..as,«.. . ?�, ., m.a.•n, .., de a:A *s �t _,,,. ,,, N . • r.. aa , s,i a�:. '�c' }' Aggression/Cruelty to Animals ❑ 0 ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ 0 0 ❑ 0 0 Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑ ❑ ❑ ❑ 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 p Please rate the behaviorlintensi of conditions which create the need for services that al rl to this child. rte"' a s.a. p�, `�z s rhx e ''`&a'x "'l'-'!: t7!!!akhdkl;p m5 4i;,,..-2-,‘G. k +. s I ' ra .4 +"4 �.7 pnwz q ,siii' lei-b �, 34 5t1" ✓ eL. • • ''',;:t`-'.--::%`-i' h %t' aAp W ' ' i ra k h Ctn � a.w �.m: ..ca 4 mss. 3 n , r, .. ° K _1. .e it..+g7R x5, '714,;57 .., ;.--% i",."S;` ,n. ., i 'l nit `r' ° r W.:. qzb,1: S`,C a,ji r : �s a z Si16 t kMh & v4 e>•k"s N i ,� a � 'E 4 i^I Y 4 �` 4 -• � ‘ �'�1 �°4 ;/ .•..,. "Xit :n.. vi ?':^vN .. v:'vra, ....:04 1..2 e. C Y':Iii'.a.,.,.. . .. .:, 1h- d" ..,. 5"4v u.# Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ O O O O O O 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 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) E 0 ❑l ❑ PA ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'/s 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE q:r Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate Aqe 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) grt Assessment/Emergency $30.25 day/$920 month(Includes Respite) Rate Effective 7/1/2008 g Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the = : WELD COUNTY BOARD OF SOCIAL s liE,)L≥s SERVICES, ON BEHALF OF THE WELD i OUNTY DEPARTMENT OF HUMAN k A N= ERVICES Deputy 'lerk to the Boar. "t ,t Chair S' nature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Walker, Kurt and Jennifer OF HUMAN SERVICES 519 Trout Creek Ct Windsor, CO 80550-3194 up By: By: Dir ctor By. C� (42.Q aci/- cQa 9$ 9 Weld County Addendum to the CWS-7A (1(10-10/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT/ 1. THIS CONTRACT AND AGREEMENT, made this date,iss- 6W7 I 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, White, Richard and Melissa, Provider ID#1545830, 3109 W 13th 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. LWS-/A(KIU-IU/99) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 CWs-/A(KIU-IU/Y9) 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 WELD COUNTY BOARD OF SOCIAL �4 SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN k "=` SERVICES 1861 / By: / !/ / / i rAE:, si ByAA-If 1t `) ht4///J Deputy J erk to the Bo=` VC* Chair SSEjnature Approval as to Substance: PROVIDER AUG 1 72011 WELD COUNTY DEPARTMENT White, Richard and Melissa OF HUMAN SERVICES 3109 W 13th St Greeley, CO 80634 le By: Q l . By: 1 1.4...01 D're for i By: 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between White, Richard and Melissa and the Weld County Department of Human Services for the period from July 1, 2011 throughJune 30, 2012. The following provisions, made this t day of (S\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#1545830. 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 writinv_ 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. 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 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 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 01)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 ❑l)Less than a ''/z hour per day 011/2)1/2 hour a day 02) 1 hour a day 02 %z) 1'h-2 hours per day 03)2'/r3 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? O Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week DI'A)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 ❑1)3 to 4 hours per week ❑I%)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'/n)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.) ❑l)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%)Face-to-face contact one time per month with child and occasional crisis intervention. 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) 01)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 a� µcreate the need for services that a..I to ,this child. Prg �aa * �ry �. 3 .;ax �i:'' e tV'Lr' 4 `Y ry a ,"!j `i Zi ii . e { M :t Y4" p ,1 P • .� h 4 a�Fv4a S+'w4" $"`p°v -',4y p ....„_t.... .,.:...;43,.t. °'' i ry . s11' t`'�" a + }, ti ` tor'V-,I '' s+ s4 24iii t.,r.�}a 't v-11-;: ._,y=!... �a liEfil; 'k.-': ,..-.1.4 R i..ak. i.: . � `.: s# i..,,.s`a",..., '. . ., , ,..�f'u 'a Wks r "''s°=` 'c __ _,. Aggression/Cruelty to Animals ❑ 0 ❑ n 0 0 0 Verbal or Physical Threatening ❑ 0 0 ❑ 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ 0 0 0 0 Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ 0 0 0 0 Enuresis/Encopresis ❑ ❑ 0 0 0 0 0 Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Example only do not complete) (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. by riVr " P n$'tk x :1: ₹ t fir ,pH ,� i % s � C y�+° Zej.' +uxtss5 -x kr 1' �' x 5 r= v y •t• s.t4 r°k:£ +., ..4.CVLIE.T:"ax's d'*"'I! r + v 4w $t., ;.?ya u �t.'..•' stwt y . 2 i* i41.*:t`" s ; ' .4,11/4k1.4.:4:%. '. k._;'V.it?'kr .,:a. ..—.. wP'.. ."..l',.ae'.,,,• `, 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 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ 0 0 0 0 • Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ 0 0 0 0 Involvement with Child's Family El El El 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 Ell ❑ 11/2 ❑ 2 ❑ 2'h ❑ 3 ❑ 3'/ 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE• f,,y • - $S'3 • �91a r 3h sv xk{><• ..e�S tw,a. � '�'.�++'lit'Ja u'�w $!�!dl,�. b 4'iw....:4 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) $23.01 1 112 "-n� +$.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) Ira $32.88 3trA +$.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 to the : � WELD COUNTY BOARD OF SOCIAL I /0) SERVICES, ON BEHALF OF THE WELD MINTY DEPARTMENT OF HUMAN ERVICES 181 t By: JP-IVY A-1 Deputy 'erk to the Boa`� Q� �,°cI �� Chair lignature/ AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT White, Richard and Melissa OF HUMAN SERVICES 3109 W 13th St Greeley, CO 80IMLt61I3''4'' � By: By:• 1^^1 t� Di ctor By: 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 10/ 1. THIS CONTRACT AND AGREEMENT, made this date, 7/1/1/ by and be n the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf 3 c', the Weld County Department of Human Services, hereinafter called "County Department"and, Willert, Melody D and Lee, Kimberly, Provider ID# 1540372, 219 N 4th St, LaSalle, CO "`"// 80645, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 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 0W7- (20.7 .3. CWS-/A(K1U-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 CWJ-/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 L % WELD COUNTY BOARD OF SOCIAL I� SERVICES, ON BEHALF OF THE WELD r I -, RNICES DEPARTMENT OF HUMAN EJ vet U COUNTY-� By: �� Li /� L, ��M1L44iAt4 //u1ByDep ' Clerk to the Boa U V 777�� Chair Signe AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Willert, Melody D and Lee, Kimberly OF HUMAN SERVICES 219 N 4th St LaSalle, CO 80645 By: By: Dir ctor n By: — 3 a0/A4 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Willert, Melody D and Lee, Kimberly and the Weld County Department of Human Services for the period from July 1, 2011 through June 30, 2012. The following provisions, made this I day of vu.L„ , 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#1540372. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C1/2 o?c51 /3 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 ❑1%)2 round trips a week ❑2)3-4 round trips a week. ❑2'/)5 round trips a week 03)6 round trips a week ❑3%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required DI)Once a month ❑1%:)Two times month 02)Three times a month ❑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? O Basic Maint.)No educational requirements ❑1) Less than a''/z hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 ''A) 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 02)8 to 10 hours per week ❑2'/:) 1 I to 14 hours per week ❑3)Constant basis during awake hours ❑3'/:)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week 02)8 to 10 hours per week ❑2%) 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. ❑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) ❑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-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. l .*, +a 1,i xsl tx k 9a xa v .. ,, ' "y':"' ;$, °$i ,"x'4 4'. S 4ii#;; ,)Sb $ J v 4 t .2.,:}. °u d9T W . Y f x� Y ., .�`.'' 1c7 .. ,. , .,: .._. .. .'• .n , ...r. .e arau°.',xyax. .q.a'.1,'..,,:,.:(..... :.:.-1..: ,..,... . ..v.= .. . '.'4. % . . Aggression/Cruelty to Animals 0 0 0 0 0 0 0 Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ 0 0 0 0 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 Please rate the behavior/intensit of conditions which create the need for services that a.r I to this child. �`4 «h t+ito- r '' r • h} s;ti z"4M ars v M '*s: s4a. s. 3r 4 a `` i - ° . .4;...{1,5•0. v . = . m y i r—, rx as £a '' .ti' { 'T e x n ti `t "s. as;.. a ‘,Ir.-z s.,. ,:...r .. , i. .. ....., i9M�, e.. `,..iMw,. w`aa,v o n.31�.�- :. ... ...,. • .:. .�.,+. .uui +� .r:&r_+S* a.._.�+ 'k7:' 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 ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ 0 ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ ❑ ❑ 0 ❑ 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 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 t '/ &�o Y § .�'X g..-xk.i� 3§"T.� �hq It d�'• � M 1... ? 4 L � ;'gy�'a39 S t rs�k"§4�' wt i^s �^a s" ;�~' dS GM R{r^�x, vF•s i L i i 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) $26.30 2 441O +$.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) egf 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 tot ' e. WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES r ' • Ito ' . . ,_' By: At a/,/. fi ��I%1.►,'16:�� '; � • l !L, Deputy i lerk-to the Bi�1� , I � Chair gnature AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Willert, Melody D and Lee, Kimberly OF HUMAN SERVICES 219 N 4th St LaSalle, CO 80645 By: By: iL'1!s 'rector By: aryl-07, 49 9 Weld County Addendum to the CWS-7A LWJ-/A(KIU-IU/99) INDIVIDUAL PROVIDER CON*4CJB(_ ly 9�� 1� 49 FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7/i III 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, Wyatt,James and Jill, Provider ID# 1590154, 38493 WCR 51, Eaton, CO 80615, 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 C/A a'.,f_3 LWS-/A(KIU-IU/99) 111. 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. 16. 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 B. :if WELD COUNTY BOARD OF SOCIAL 4s La SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN ERVICES 4 A, l1\ .'r' �^ By kt4u /tva 4(bu Deputy perk to the Boa ,�� Chair Si / AUG 1 7 2011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Wyatt, James and Jill OF HUMAN SERVICES 38493 WC 51 Eaton, 0615 By: - By: D rector By: • 3 c>70//-ac y3 WELD COUNTY ADDENDUM all JUL 14Lin Oi To that certain Individual Provider Contract for Purpose of Foster Care 1 i{9 Services and Foster Care Facility Agreement (the "Agreement") between Wyatt,James and Jill 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 O,414 , 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#1590154. 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 S-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 ❑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 Di'4)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 ❑l)Less than a''/2 hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) I'/:-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 ❑1%z)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? ❑ Basic Maint.)0-2 hours per week 01)3 to 4 hours per week ❑1%)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%)21 or more hours per week Comments: A 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. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T I. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) 01)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/intensit of conditions which create the need for services that a..l to this child. h�i* ' '* please ₹warn‘,..1't ' Pr 4 r if_ }:r y ,,e.x�, y"i . 's"ysi' x y °xs i y•i.. . "'y `1,'”: f".. W"*#-- ' '4 e'f- '°,'2g. kr t"i2;a r t x � '404., bl v * .." ` fi °Cja.3:k'a � '.'s . x,, a a r s Sx r,,s i ' ' a = 4�>.- x ..° .,;1.7.1.-r-P 4ib. s :• ' . k . fa•` f >ri w 7't f s ti a .t' .. } is y i YPory'Ga I _. z .1"r i • v I,## s r 1. 'vri ... r i 4f�� .h. s — % . ...g c rs { f 4-7'.' �3� 2 �C, �.<' f.�ew;t.mIx.,..1:-...,R ... ..< «• .,�.�?• Lk v��ciL'tv+�§"v 'v°2i��+t Aggression/Cruelty to Animals O ❑ ❑ ❑ O O O Verbal or Physical Threatening O O O O O O O Destructive of Property/Fire Setting O O O O O O O Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ o ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions O O O O O ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ O O O Runaway ❑ ❑ ❑ O O O O Sexual Offenses ❑ ❑ ❑ 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 a..I to this child. laiiialgiR.#s* ' k t" ,r 'Yp 't1-:5:,4 ;Y�. '41; a'S . xt n,.4;+Natectif11; y, k o. x. iitr `.; e i ! 4 ,_ a r $ 9i '. .A ^4..t'' ,. i 4 e '� ' ...�'"�tr r.. v. k}t 4.'1•. 't5.� "'km YF1 ; NI - ty �k . 1T?�\7{u4 k} b Sik„ r .:"._ :{ w.., t... .l-sr :: .. .,,�.>,"... „ .i e. °d. ... a. ." ..:,u . };' 'k+;' " : ..:. a 'sx.. Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ 0 0 0 ❑ 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe, ❑ ❑ ❑ ❑ ❑ 0 ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ 0 0 0 Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ 0 0 0 0 Requires Night Care ❑ ❑ ❑ 0 ❑ 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7/ • (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE 77 RATE TABLE AA t di ! 4 f ti ' .`� w',•, ii ,. , .≥^fs, .#ErNE9 , • s •rrt •• 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) $19.73 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 112 4.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 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) $36.16 3 112 4.66 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 enti 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 4 E La COUNTY DEPARTMENT OF HUMAN SERVICES r Ptio 361 � _} By: /�I/�i '.i' ,. .�/_ZT.,i � Y` A B . pi Deputy ' erk o the toot Chair S' nature ..... AUG 1 72011 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Wyatt, James and Jill OF HUMAN SERVICES 38493 WCR 51 Eaton, CO 80615 By: By: irector By: ieR Write 9 Weld County Addendum to the CWS-7A Hello