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Home My WebLink About20102196 MEMORANDUM fit t in' DATE: September 16, 2010 IlDTO: Douglas Rademacher, Chair, Board of Co my Conl;nissioners FROM: Judy A. Griego, Director, Human Servic Depaniment COLORADO ) RE: Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreement and the Weld County Addendum to those Contracts between the Weld County Department of Human Services and Various Providers — To Be Placed on Consent Agenda Enclosed for Board approval are Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreement and the Weld County Addendum to those Contracts between the Department and Various Providers. Please place on Consent Agenda. The major provisions of these Agreements are as follows: No. Provider/Term Type of Facility/Location Daily Rate 1 Andrews, Mark and Susan Foster Home $16.32-$40.11 July 1, 2010 — June 30, 2011 Eaton, Colorado 2 Beaman, Diane and Chad Foster Home $16.32-$40.11 July I, 2010—June 30, 2011 Greeley, Colorado 3 Carter, Jeremy and Susan Foster Home $16.32-$40.11 July 1, 2010 — June 30, 2011 Greeley, Colorado 4 Clark, Rande and Beverly Foster Home $16.32-$40.11 July I, 2010 — June 30, 201 1 Fort Lupton. Colorado 5 Corliss, Wade and Loni Foster Home $16.32-$40.11 July 1, 2010 —June 30, 2011 Greeley, Colorado 6 Erbacher, Dan and Hallie Foster Home $16.32-$40.11 July 1, 2010 — June 30, 2011 Greeley, Colorado 7 Fisher, Matthew and Claire Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 8 Fisher, Steve and Joletta Foster Home $16.32-$40.11 July 1, 2010 — June 30, 2011 Greeley, Colorado 9 Gariepy, Susan J. Foster Home $16.32-$40. 11 July 1, 2010—June 30, 2011 Greeley, Colorado 10 Garvey, Collin and Foster Home $16.32-$40.11 Stewart-Garvey, Charlotte Firestone, Colorado July 1, 2010 —June 30, 2011 11 Gerardy, Jerry and Priscilla Foster Home $16.32-$40.11 July 1, 2010— June 30, 2011 Evans, Colorado i 9j (pe—/C C\- a 1- kJ 2010-2196 12 Gomez, Oswald and Christina Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Fort Collins, Colorado 13 Goodman, Bob and Katie Foster Home $16.32-$40.11 July 1, 2010—June 30, 20 I I Windsor, Colorado 14 Hays, Stephen Dale and Chantel Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Fort Lupton, Colorado 15 Heimer, Sara Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 16 Hernandez, Roberto and Margarita Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Fort Lupton, Colorado 17 Hoel, Elizabeth Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Dacono, Colorado 18 Holmgren, David and Dawn Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Windsor, Colorado 19 Hunt, Olen J. and Nina Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 _Greeley, Colorado 20 Hymel, Chad and Tiffany Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Longmont, Colorado 21 Kniss, Kevin and Kelly Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Thornton, Colorado 22 Kohler, Christopher and Foster Home $16.32-$40.11 Vance, Michelle Dacono, Colorado July 1, 2010—June 30, 2011 23 Maronek, Dennis and Patricia Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Firestone, Colorado 24 Martinez, Andrew and Jeanna Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Evans, Colorado 25 Mauk, James and Harriett Foster Home $16.32-$40.11 July 1, 2010 —June 30, 2011 Johnstown, Colorado 26 McCreery, James and Tammy Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Eaton, Colorado 27 McGee, Donna Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 28 Mellman, Jeffrey and Letha Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Eaton, Colorado 29 Mena, David and Marie Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 30 Middleton, Brian and Deborah Foster Home $16.32440.11 July 1, 2010 —June 30, 2011 Greeley, Colorado 31 Montez, Joseph and Alexis Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Evans, Colorado 32 Moore, Earl and Patricia Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Lochbuie, Colorado 33 Parker, Brian and Beryldell Foster Home $16.32-$40. II July 1, 2010—June 30, 2O11 Greeley, Colorado 34 Paulsen, Larry and Helen Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 35 Pierce, Kris and Larry Foster Home $16.32-$40.11 1 July 1, 2010—June 30, 2011 Greeley, Colorado 36 Pluma, Mike and Annette Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Kersey, Colorado 37 Ramos, Julian Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 38 Rasmussen, Dennis and Diane Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Johnstown, Colorado 39 Redding, Christopher and Sonja Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 40 Reussow, Robert and Tracy Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 41 Ripka, Gary and Jennifer Foster Home $16.32-$40.11 July 1, 2010— June 30, 2011 Greeley, Colorado 42 Risner, Larry and Foster Home $16.32-$40.11 Vivanco, Katherine Johnstown, Colorado July 1, 2010—June 30, 2011 43 Ritter, Thomas and Deborah Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Firestone, Colorado 44 Roderick, Douglas and Kelli Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 45 Rogers, Jeffrey and Tami Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Firestone, Colorado 46 Rothe, Terry and Marilyn Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 47 Rush, Phillip and Shannon Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Aurora, Colorado 48 Sands, Corey and Amy Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 49 Schmidt, Donald and Constance Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Windsor, Colorado 50 Sevestre, Lewis and Maureen Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 51 Shindle, Danny and Andrea Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 52 Skeldum, William Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Johnstown, Colorado 53 Steele, Dana and Cassandra Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Johnstown, Colorado 54 Steitz, Daniel and Natalie Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 55 Van Den Elzen, Dawn Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 56 Vincent, Jessica and Ryan Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Greeley, Colorado 57 Wade, Michael and Jodyne Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Windsor, Colorado 58 Walker, Kurt and Jennifer Foster Home I $16.32-$40.11 July 1, 2010—June 30, 2011 Windsor, Colorado 59 Willert, Melody D. and Foster Home r $16.32-$40.11 Lee, Kimberly LaSalle, Colorado July 1, 2010—June 30, 2011 If you have any questions, give me a call at extension 6510. LAWS-/A(K I U-I U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 2P"? JUL 15 PM I: 24 1. THIS CONTRACT AND AGREEMENT, made this date, E "A / o�{O/(7 by and between the Board of Weld County Commissioners, sitting as the and f Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Andrews, Mark and Susan, Provider ID#1559384, 22305 WCR 76, Eaton, CO 80615, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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(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,W3-/H kK 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 WELD COUNTY BOARD OF SOCIAL ♦�' Lam SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Deput lerk to the ♦ BSichair Sig aturea SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Andrews, Mark and Susan OF HUMAN SERVICES 22305 WCR 76 Eaton, CO 80615 By: By: ctor 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 Andrews, Mark and Susan and the Weld County Department of Human Services for the period from July 1,2010 through June 30, 2011. The following provisions, made this I day of 2010, are added to the referenced Agreement. Except as modified hereby, all terms o he 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#1559384. 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)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 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 01)Less than a''/x 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 ❑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 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 I. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 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%n)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..l to this child. 'gbis,....-a.=..15...1.-,.-- y1 , V:/....?.,1; ? i ,tip r - y ,: ';',...,•:-.7, . r y ,,,',..:,.'.:,/,:j. t ' +---,,,,:$.;:;-:"...""..A4-.7';'::r.--.5e,y - € x ��t° �, s Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ 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 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 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-; (Exhibit B) WELD COUNTY DNS 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 n ..'�*..., c„ [t.,. ,x..< :c;-=';'..K.:2 ,s ;.. ''`i:;1re+. . ' ....,;(1'tx..sajal.a sh..,:j.�atie, Gr',,vt'.s.a.. . , , >," f 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 please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems O 0 0 0 0 0 0 Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ ❑ 0 ❑ ❑ 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/ ❑ 2 ❑ 2% ❑ 3 ❑ 3'/s 7 Weld County Addendum to the CWS- (Exhibit C) • WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE F � ea s d1 y 3 . A•e 0-10...$16.32/da $496/month County Basic V4A•e 11-14...$18.05/da $549/month Maintenance Rate A•e 15-21...$19.27/da $586/month vira +Res•ite Care$.66/da $20/month $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) 111 $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) iN $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) zWEI $36.16 3 112 +$.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 Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 1861 412 By' dtkr Deputy 7 erk to the � , U Chair ignature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Andrews, Mark and Susan OF HUMAN SERVICES 22305 WCR 76 Eaton, CO 80615 By: By ✓ i/ 1/ ! CctoQt By: �I �� 9 Weld County Addendum to the CWS-7A L W S-/A(KI U-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 72 nll) by and between the Board of Weld County Commissioners, sitting as the Bo d ofjoci6l Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Beaman, Diane and Chad, Provider ID#1560953, 2808 22nd St Rd, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 ,R2/Z) /�L Lwa-IA(K1U-imvv) 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 th WELD COUNTY BOARD OF SOCIAL IEn L SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES 861 By: Deputy ' lerk to the kJ' ra�� Chair Si nature SEP 2 0 2010 Approval as to Substance: �I PROVIDER WELD COUNTY DEPARTMENT Beaman, Diane and Chad OF HUMAN SERVICES 2808 22nd St Rd Greeley, CO 80634 / f!` By: /� By: l di, irect r By: WELD COUNTY ADDENDUM IQ/n, I 6 Ay To that certain Individual Provider Contract for Purpose of Foster Care en 9. Services and Foster Care Facility Agreement (the "Agreement") between sy Beaman, Diane and Chad and the Weld County Department of Human Services for the period from July 1,2010 through June 30,2011. The following provisions, made this I day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of e 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#1560953. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. ,YC'/D-6'/%) -- 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 C W 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 (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? 0Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑I%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%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month ❑1/)Two times month 02)Three times a month 02%)Once a week 03)Two times a week 03%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements 01) Less than a ''/2 hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 '/a) 1'/,-2 hours per day 03)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 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 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond at=e appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'%)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'A) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑l)Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑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) ❑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 • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/mtenst of conditions which create the need for services that a••I to this child. rE', Vii'' t "A x k..jr,M' -y^am r v t *r G "t.4)4 ' r1S IL:,..' ti .t a p . s 3::il t . (. -v eyr r x ,} i 'k S• s1t4 Pi °4� iyt s ) #; oL{�. fie* x 4 %,74^ 5. Y 3 :r =s ce,';# w .. OK #i`e e2.1,;-4,4—. svn,.- .. G#:ssx{k. '� Uc; ' 9V�At. ..�a ., .r.+.i;. .. .. .. Aggression/Cruelty to i! Animals 0 ❑ ❑ ❑ 0 ❑ 0 Verbal or Physical Threatening 0 ❑ ❑ ❑ ❑ ❑ 0 Destructive of Property/Fire Setting 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 0 Presence of Psychiatric Symptoms/Conditions 0 ❑ 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 ❑ 0 0 Sexual Offenses ❑ ❑ 0 0 D 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..ly to this child. .a 'a�, "',u ' ; -(4';i ,F -',Z 'r; r „ j.�. X?r: y tx',I r `, +.. i' "" r e a9 i E c t ,' s a 1 i%'6 tiliff ._5it.4 4a._ ,4Vi„ � .r ; ..w. ',R"Hit.av,.,..:�,.s sti ,. ..4 ! Y ;3114 9_$t ' z ? S .S. P Inappropriate Sexual Behavior 0 0 0 ❑ 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ 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 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ III 0 0 0 0 Eating Problems ❑ ❑ ❑ ❑ 0 0 0 Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 Ell ❑ 1'/z 1112 ❑ 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 ' a Iry . 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 ($586/month) jig +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) wig $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) kgi $29.59 2 1/2 .1.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 rif,Z +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4. 4 $39.45 +166 Respite Care TRCCF Drop Down Total Rate=($40.11 day/$1220 month) Assessment/Emergency Es Rate $30.25 day/$920 month(Includes Respite) (30 day max) eCt 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 IS La COUNTY DEPARTMENT OF HUMAN SERVICES sue' By ` I%/ //. ," .., %�41 B :_ ,„1z Deputy.r erk to the'.y' U Chair ignature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Beaman, Diane and Chad OF HUMAN SERVICES 2808 22nd St Rd Greeley, CO 80634 By: By: A, - lcov/l i ctor \ at2/G-a/Y 9 Weld County Addendum to the CWS-7A t_ANN-/A(KIU-1U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND )n,� FOSTER CARE FACILITY AGREEMENT ✓1 ?9 1. THIS CONTRACT AND AGREEMENT, made this date, I JAI() by and between the Board of Weld County Commissioners, sitting as the Boaodal Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Carter,Jeremy and Susan, Provider ID#1556173, 8108 Surrey St, Greeley, CO 80634-9342, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 ewS-/A(Klu-luivv) 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(K1U-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 SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES ..0 r` = ''.142 By' Deput /lerk to the :`CU�� Chair i naturesEP 2 0 2010 Approval as to Substance: �" PROVIDER WELD COUNTY DEPARTMENT Carter, Jeremy and Susan OF HUMAN SERVICES 8108 Surrey St Greeley, CO 80634-9342 BY: BY: �— Dir ctor By: 3 WELD COUNTY ADDENDUM 'n`o✓O 29 To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Carter,Jeremy and Susan and the Weld County Department of Human Services for the period from July 1,2010 through June 30,2011. The following provisions, made this / day of 2010, are added to the referenced Agreement. Except as modified hereby, all terms th 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#1556173. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. a'C?lD— / � Weld County Addendum to the C W 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 ❑l)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 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 ❑l'/)Two times month 02)Three times a month ❑2'/x)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''/I hour per day Iv.) v.hour a day 02) 1 hour a day 02 %) 1'h-2 hours per day 03)2'h-3 hours per day ❑3'/:)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.)No special involvement needed DI)Less than 5 hours per week ❑1'/)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 01)3 to 4 hours per week ❑1%:)5 to 7 hours per week ❑2)8 to 10 hours per week 02'/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. ❑1%z)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) 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) DI)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a.i I to this child.lilt: £eau 4 4y+A ' 1 � �'tiv:$k�:t� e'ws..'s+�"v� ?. �; c. r` o:�' ,.... .. , '?ID, e,...,....�. 3.4 ,,.,,"�ti,sa of}r.r. = .. . r,.a'' Aggression/Cruelty to Animals 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 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intend of conditions which create the need for services that a..I to this child. z r r Inappropriate Sexual ❑ 0 ❑ 0 0 0 0 Behavior Disruptive Behavior ❑ ❑ 0 0 0 0 0 Delinquent Behavior ❑ 0 ❑ ❑ ❑ 0 0 Depressive-like Behavior ❑ ❑ 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ 0 ❑ 0 ❑ 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ 0 ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ 0 Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 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 $' ^.'° �"� r�1�•., �.�'� < n a i a 7a`m s�fls�C'� s :fin' .aaL'°�`a,.•f., � � �. i . '� ��s.: rca{'�a,.<,......r. 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) $19.73 1t +$.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) oge $32.88 3 +$.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) fAl 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) (30 day max) 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 ► COUNTY DEPARTMENT OF HUMAN y ✓ SERVICES 1 i . � v By: j AJ1L4 .:.��1 � .:%.L�� Bri p / v Deputy erk '�� ` -' ~' Chai Signature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Carter, Jeremy and Susan OF HUMAN SERVICES 8108 Surrey St Greeley, CO 80634-993__42---�,, By: I BY: 1 `�J Dir ctor By: 9 Weld County Addendum to the CWS-7A WS-/AtKIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT imp C id 1. THIS CONTRACT AND AGREEMENT, made this date, ) c fJC) by and b vIe the Board of Weld County Commissioners, sitting as the Boa o ocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Clark, Rande and Beverly, Provider ID#1561240, 901 Greenwood Ct., Fort Lupton, CO 80621, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 ae /c-O2 19 L W S-/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 (KW-10/99) 4.4. 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 ' WELD COUNTY BOARD OF SOCIAL • SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Depu Clerk to the 'f+ "��pp� Cha Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Clark, Rande and Beverly OF HUMAN SERVICES 901 Greenwood Ct. Fort Lupton, CO 80621 By: �J S�% YOU 4t& // a,elate i//y/lo By: / 3 D?C/L'-o?'`9 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Clark, Rande and Beverly and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this I day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of a 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#1561240. 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 ❑1)One round trip a week ❑1%:)2 round trips a week 02)3-4 round trips a week. 02'A) 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 01%)Two times month 02)Three times a month ❑2%)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 ❑1)Less than a ''/3 hour per day O1'A) 'A hour a day 02) I hour a day 02 /) I'/-2 hours per day ❑3)2'A-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 011/2)5 to 7 hours per week 02)8 to 10 hours per week 02%) 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 ❑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. ❑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. ❑2%)Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/mtensit of conditions which create the need for services that a..I to this child. �,...r.:::::`:!"::::::''':::.%7:41::::s... ' k �g y' y ase+i :.II. y�,w-av+ u-, Wi � �, q ,w. -',Pei,;-:..,-,.-.'.--:- 'cws,. ..J...-N. za S y "� i5, ,4:814 w � ..�.7x.k �...�,,.� a .,a..., ,.�. �.$a§v,a ul9�:a�.�4raY�.x�., ,A..s,:t...'a. . .. ,. .. :.. w ........... .ax.�ti��. 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 Stealing ❑ 0 0 El 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ ❑ 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ 0 0 0 Enuresis/Encopresis O 0 0 ❑ 0 0 0 Runaway ❑ ❑ ❑ ❑ 0 ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ 0 6 Weld County Addendum to the CWS-7A ' (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 ralif3W7/7r1rt r a "ittrYrc °.?8 ` i §a* m ,x' '4 � s a ' yx; 6r ? a # •ks� ','..;,,:c.'„*:zi. 44.411; 411 , y. "x; "�"x*t . '*.N1,a a "v w67 ,.a1. ry.&..4.1 i v:''.1'. . IT.?k a:...,:5,;,=:4444.1,',7q}1.. ro !.1�vv44 4 a= cl: p ,,..... ;e 'w'v u.,.,zadA.. .vq r+.. r3.A:x.." , ... .., .„a , . .. ' , 3._.... 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 0 El 0 0 please complete the Medically fragile NBC) Emancipation O 0 0 0 0 0 0 Eating Problems O 0 0 0 0 0 0 Boundary Issues O 0 0 0 0 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑I ❑ 1% ❑ 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 • ,vyamS . " Hk5Y'H. a } ' Pt Age 0-10...$16.32/day_($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance tirq 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) rfft $23.01 1 1/2 iegt +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 tiw +$.66 Respite Care 1.41 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) 44 $36.16 3 1/2 +$.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 Si Rate Pi $30.25 day/$920 month(Includes Respite) (30 day max) kifei 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 y� ; . WELD COUNTY BOARD OF SOCIAL /� �,f, • SERVICES, ON BEHALF OF THE WELD /� COUNTY DEPARTMENT OF HUMAN `::i SERVICES Iv kiQ.. By: l/ti/ //_ ��. �4 rBl� .►; 1', By' /lam-/ Deput er to the C� �� Ch a r Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Clark, Rande and Beverly OF HUMAN SERVICES 901 Greenwood Ct. Fort Lupton, CO 80621 By: By:a YJ! ?/Y<' Crector q ��yy �j�J� l By:�Ex%Z A add- 7/yho 9 Weld County Addendum to the CWS-7A (KIU-1U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT I 20j0 il!I 20 A 38 1. THIS CONTRACT AND AGREEMENT, made this date, TL ! oft/ by an between the Board of Weld County Commissioners, sitting as the Boardtf Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Corliss,Wade and Loni, Provider ID#1547483, 26649 CR 60 1/2, Greeley, CO 80631, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 aevo- a /9 - 1:WS-/A tKIU-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 I:WS-/A(KIU-IU/99) 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to y>• �� WELD COUNTY BOARD OF SOCIAL fi S I La SERVICES, ON BEHALF OF THE COUNTY DEPARTMENT OF HUMAN WELD �!`ys�', SERVICES 0.: By: � I////iii �i�:!„jl. t? * -. ByLk)�_Y- (/ Pan��) Depu t lerk to the T. (j N \' ' / Chair Ignature +•-► SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Corliss, Wade and Loni OF HUMAN SERVICES 26649 CR 60 1/2 Greeley, CO 80631 By: 1 By: Dire t By: 01IX (`.PII.Q1.4,4, 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Corliss, Wade and Loni and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this 11 day of ,\iI , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1547483. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided,the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. 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. 7 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 ❑I)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 01)Once a month 01%)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 ❑I)Less than a''/3 hour per day DIM)1/2 hour a day 02) 1 hour a day 02 %) 1'/2-2 hours per day 03)2'/2-3 hours per day ❑3'/:)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑I)Less than 5 hours per week ❑1'/)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 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 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. 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. ❑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 (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. '..-- :;45!...:..- 4 a ':.%.,,:r..- g i••.:4 ' ;sro., k i ;i:-.,,,,,!„,,b '9d ,'r.Z e y a4 a'3 ° muro•�ta 7 x y �x i fr 4 �,.' zk: 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 ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ 0 0 0 0 0 Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..l to this child. � '� P t 49 yip � P t 3 �k .! : a qty �e °' ,a:.+, .;^x v ".sn:a; :., '~..&.^a,�e.,_. :sx�lsea:' . e ., :;e. . . .. ....... . .�..+. 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", ❑ ❑ ❑ ❑ ❑ El ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 0 0 Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ 0 Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ 0 0 0 0 0 0 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 Ell ❑ 11/2 El 2 in 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 r ' :9-0 Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate t.ZAiAge 15-21...$19.27/day ($586/month) 4444 +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) • ts 241 rat $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care ittf 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) .11121 $36.16 3 112 Thai +$.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) AssessmentlEm ergency Rate t c $30.25 day/$920 month(Includes Respite) (30 day max) 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 • . rP SERVICES r!r Ism By �l/Ii// G i.: !��.�':V_�.�� ' B if'[ Deputy r erk to the Bo% �� C_ a r Signature `�� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Corliss, Wade and Loni OF HUMAN SERVICES 26649 CR 60 1/2 Greeley, CO 80631 By: By: k' 1 D ector By O&1IU- aeiZ%-ai� - 9 Weld County Addendum to the CWS-7A 1-WS-/A(KLU-I(1/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT //' ' 10/0 di29 a,„a,„1. THIS CONTRACT AND AGREEMENT, made this date, J1 / .2-6/V by and between/2, the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of U6 the Weld County Department of Human Services, hereinafter called "County Department" and, Erbacher, Dan and Hallie, Provider ID#1546381, 3850 Cheyenne Dr, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 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 UN/N-/A KIU-lU/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 ♦ SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES sei By: ►�'�' ' °�Ir" By Deputy lerk to the V'.? � Chair S' nature kJ SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Erbacher, Dan and Hallie OF HUMAN SERVICES 3850 Cheyenne Dr Greeley, CO 80634 • By: By: N CLA-CA-- irector By1 //.'fJ s i A i 3 WELD COUNTY ADDENDUM lOtc�h� To that certain Individual Provider Contract for Purpose of Foster`Cai'q Services and Foster Care Facility Agreement (the "Agreement") between Pf b. Erbacher, Dan and Hallie 2 05 and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this day of � , 2010, 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#1546381. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. 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 (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 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? 0 Basic Maint.)No participation required ❑I)Once a month 01%)Two times month O2)Three times a month ❑2'/)Once a week O3)Two times a week 03 v 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 ❑l)Less than a '/a hour per day 01%) hour a day O2) 1 hour a day O2 ¶4) 1'/:-2 hours per day O3)2'h-3 hours per day ❑3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ 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 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? 0 Basic Maint.)0-2 hours per week ❑I)3 to 4 hours per week 01%)5 to 7 hours per week O2)8 to 10 hours per week ❑2%) I I 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.) ❑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. 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? O0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..l to this child q y axe ax c ti.-A+1` .icytuf-: ro .�„ • a§ . y a* +'dun ; ea. fit; it^' i „,.e,. "sw:�+.,«�..<u u'�c ..V '�...�.'"1 "�.,4.4.:2.i:- $ is.i. . : .. ri • i. : a'"P xVf. * a"1s, s 'iV �4 . .t �`,` t 5 "',Z c °dam*‘° Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 0 0 0 ❑ 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 O 0 O O O 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 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway O 0 0 0 0 0 0 Sexual Offenses O ❑ O O 0 0 0 6 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DRS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/mtensl of conditionyss which create the need for services that as.1, to this child N`--.- ' -'`, s r a* ,d', cam§ r ''0*i r ', :s a`mA ;ding,✓u;'k s"trd ire?„1 a°s `., { :ya G'e't'* :..kk tFM 4t§ �}:-# M 4' 4 �114 'C'",: a&� ' S¢ .t.'3 1 ..tIgi`ti."2 -.ter�s�}' 3li;;;i:r - s : °�: +. s�,:: 7y s., "` N' '';:-'4'.'• 1.y a *..d x gi,c i.l ��ao-a.•v, zSS34 ',15•1',,l; ;,, • � s.z 1. 1,01 r 1., " } L'a: F 2 v" .::;‘•','";Z-.ca a V.3:3-%<e:c A�,N".�.. :., , }.. :-:-.:41.:'1.t°�3i.x:'`w`r nr:. .. ,:�... ."ti.e • . .,. . .. ' ..,:,'s°°" Inappropriate Sexual Behavior 0 0 CI 0 0 0 Disruptive Behavior ❑ ❑ 0 0 ❑ 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 ❑ ❑ ❑ 0 0 Medical Needs (If condition is rated"severe", 0 ❑ 0 ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ ❑ 0 0 0 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ 0 ❑ ❑ 0 0 Involvement with Child's Family CI CI CI CI CI CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 2V2 ❑ 3 ❑ 31/2 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE ' , Aqe 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 ($586/month) tat +Respite Care$.66/day ($20/month) $19.73 1 .414 +$.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 4.66 Respite Care Total Rate=($30.25 day/$920 month) ipt $32.88 3 +$.66 Respite Care erM 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 Rate a $30.25 day/$920 month(Includes Respite) (30 day max) 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 /�J ♦ S La COUNTY DEPARTMENT OF HUMAN SERVICES By: Deput f Jerk to the .�.• -�j Old Signature `�•� �� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Erbacher, Dan and Hattie OF HUMAN SERVICES 3850 Cheyenne Dr { Greeley, CO 80634 By: l By: �CLrt, Di ctorBYattl (" 9 Weld County Addendum to the CWS-7A UWJ-/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 ,4011) by and between the Board of Weld County Commissioners, sitting as the Bo d o odial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Fisher, Matthew and Claire, Provider ID#1532312, 5022 W 2nd St Rd, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 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 LWS-/AtKIU-IU/99) 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to the ""*+ WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN %SERVICES tuI By: i ,I///I�/' �ti:�.ii`s_ �� -� B : Deputy .rk to the Bo Q 1C Ch it ignatii 2 l7 2010 Approval as to Substance: PROVIDER JJttl WELD COUNTY DEPARTMENT Fisher, Matthew and Claire OF HUMAN SERVICES 5022 W 2nd St Rd Greeley, CO 80634 By: By: C X� O_ Die for By: 3 ,X/C--(9 /94 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Fisher, Matthew and Claire and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this i day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms th 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#1532312. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. orif ] 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? 0Basic 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 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 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? 0 Basic Maint.)No educational requirements 01) Less than a''/3 hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) 1'h-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 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.) ❑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 ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY OHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intent of conditions which create the need for services that a..l to this child u t j $ 4 5& :" k ; " a'447 P- YEA q ass 3 .a 9 41 ryry��,Ey,%¢5 Cs: , S a i',t 44'y 6+.e `e°IC; + g !'rk -x'4' tx IR' P.. .. i k inl • Y�1 * p „ - 0.y Ya'.+:. fa [' S :::.":',717.,,! V. +E#* xfi r? .. asP aPu...� tcatt#„{�: .�.m.ka4a K ,b ' 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 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intend of conditions which create the need for services that a'I I to this child. -ita ;,.r s s r`K'�'� ., �. r 1t ' z --ifia:tFatt*%+,3p+.s Y,-tv--:` • r °y a y ' ;';'„,;\ ,- 4 1, '^k C a- � d. *�ra�. '� ro-' � v� ,p " a. .jr. ::a r r iiryv`4.i . Hi $1& ."e t� m ry a ---,,,}&}':y, - • fl.'1 •• w<•j d^'4M1 A#�f t '' 3 'kfi £yp+�?,i^�a��,A"'u.k '? .'—"�..'��ar.9rvS `" ,�.�T"^ ..:T-7:1::..-�.. aE,�a�a .•�;�t..�'5a�• �a d..- .,. .... .,� :;. x.. F ,,::e•.e .':..": 3# 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 ❑ Medical Needs (If condition is rated"severe", ❑ 0 0 ❑ ❑ 0 ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 0 0 Eating Problems O ❑ ❑ 0 0 0 0 Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care O 0 0 0 0 ❑ 0 Education ❑ ❑ ❑ ❑ 0 0 0 Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ El 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2'V ❑ 3 ❑ 3'% 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE az3i3 � � da is y� x�°ry x5.' Fig A.e 0-10...$16.32/da $496/month County Basic 01: A.e 11-14...$18.05/da $549/month Maintenance Kg ...rats: Rate btiE A.e 15-21...$19.27/da $586/month +Res.ite Care$.66/da $20/month $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) fr $26.30 2ref4-$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$.66 Respite Care 114 Total Rate=($30.25 day/$920 month) EKY $32.88 3 +$.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) 1314 4 $39.45 TRCCF Drop Down ($ +$ Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) itiS mtt 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 • 'E La\ COUNTY DEPARTMENT OF HUMAN SERVICES 1 "�•. �► 1861 l �-' By: By ets Deput Y lerk to the CI a' Chair ignature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Fisher, Matthew and Claire OF HUMAN SERVICES 5022 W 2nd St Rd Greeley, CO 80634 By: By: C-12-A.:0 D ecto By: at(W)-- 2/ 9 9 Weld County Addendum to the CWS-7A GWS-/A(KlU-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 Ani j) by and between the Board of Weld County Commissioners, sitting as the Bo rd Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department"and, Fisher, Steve and Joletta, Provider ID#1515472, 1201 N 1st Ave, Greeley, CO 80631, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 roc - a/9� L W S-/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 S-/A(KIU-IU/99) r.6. To give the provider a written record of the child's admission to the home at the time of placement. To give the provider a written procedure or authorization for obtaining medical care for the child. 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 • •r_i,.r WELD COUNTY BOARD OF SOCIAL } /,v SERVICES, ON BEHALF OF THE WELD • COUNTY DEPARTMENT OF HUMAN SERVICES By: I .% tet, , �:! 't f�•�r i , Deputy•• erk o th'j y��'«�a� Chai Signature SEP 2 0 2010 Approval as to Substance: fi""" PROVIDER WELD COUNTY DEPARTMENT Fisher, Steve and Joletta OF HUMAN SERVICES 1201 NI 1st Ave Greeley, CO 80631 By:, By: cOZe - 14Yh Direr r gr�-- By: 3 c,?D%n , /il WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Fisher, Steve and Joletta and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this I day of 2010, are added to the referenced Agreement. Except as modified hereby, all terms o he 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#1515472. 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 ❑1)One round trip a week 011/2)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 ❑1'/)Two times month 02)Three times a month 02%)Once a week 03)Two times a week 03%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a 'h hour per day 01%) 1/2 hour a day 02) 1 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 O1) Less than 5 hours per week ❑1/)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 ❑1'%)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'/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.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/)Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoingcrisis 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 • (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. +;zjilStisiCa;�t c x�r" * A: w a a ac 4',..1.114:0'."..!, + as '# w <: e z .;t, P i.,@ . . +'7 0*.;..i ''`" ?r. *L"m :+4i31,v 44b. # y :"€ i R,,1 '4,% it'}'4. .k. yLis fill S2.§' x �r i §r3 h+Yi .• v.tlit:22:2.:.- :,.*iLl iati 't °""�, F 4tpmerfAt 4i S?G 't^ ';:€{4 4A fk M ' h k 't '°e Y . -,. ,+ a.. ... 3-v�..,::,. F Vie vL.v"�°.+�P �' � +'� rAl ..a,,, . . .... . %. ..,.,... Aggression/Cruelty to Animals 0 ❑ 0 0 0 0 0 Verbal or Physical Threatening ❑ ❑ ❑ 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ 0 0 0 0 0 Self-injurious Behavior ❑ ❑ 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS-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..I to this child 1 .. 't ~ ,,,,..5?..',;-"":%.::.1,F.':' �"s.Lf� �hi�w P k�-s ••.-;',2•••:...:r4-:: � 4 q, c j. �v•''tea eta s-� t r§ r ari :: :4•••••;_ f Mw�+: t �` ''4 5= ,s: nf°v s, a's , . i ri g v ,,,:;;•:':;;;:.i g:pitge'v=y'Y e s .n. a. „,...:;;$3,-"--..-:;,::„,;!,/,,,o- t 4 u��' '9' �� 5� �ha} 3runavM.�i, .a:.::ts. vrmEk�'�: K.=..sxi4., f: 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", ❑ ❑ ❑ 0 ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation 0 0 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 Education ❑ ❑ 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ l'/x ❑ 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 � �T4 .ta� • nit (t'$6 :x S Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 +$.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 tiA Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) )44 $36.16 3 1/2 +$.66 Respite Care is 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 rat Rate $30.25 day/$920 month(Includes Respite) (30 day max) )'„F 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 zfi COUNTY DEPARTMENT OF HUMAN SERVICES Ism Byi�/dam , !�� I%lrs �1 B a Deputy' erk.to th-` Cha r Signature �•...i� SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Fisher, Steve and Joletta OF HUMAN SERVICES 1201 N 1st Ave Greeley, CO 80631 By: By: 9.44- irect �� By: _ << y.�>., ,9()/(7.--c›?/9 9 Weld County Addendum to the CWS-7A S-7A LWS-/A(KIU-lU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7/1O0 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, Gariepy, Susan J, Provider ID#1553740, 5151 W 29th St#1706, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 , X7i(7'— UN/N-/A(K1U-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 WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES 1161 By: Deputy!�erk o the B:4 LLJ' 11 IS Chair Si nature Approval as to Substance: PROVIDER SEP 2 0 2010 WELD COUNTY DEPARTMENT Gariepy, Susan J OF HUMAN SERVICES 5151 W 29th St#1706 Greeley, CO 80634 By: By: .51-1-442-A-6— f7 'recto By: 3 c2Cic-a I 9� WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Gariepy, Susan J and the Weld County Department of Human Services for the period from July 1,2010 through June 30,2011. The following provisions, made this 18 day of Su fy , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1553740. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator,prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. �evz) •-(ap) 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 ❑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'h)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''/z hour per day 011/2)%hour a day 02) I 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? 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%) 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 ase 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%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.) ❑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 ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7. (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..I to this child. e tp s --Cyi i' siatOa'..e.,� "�, :sx:w v 'rw .s t ''Ii h .,+# 5 ,- iI 8f • �s x•a. a '�. .a�v " �. 'ind apt r "'t ` i" c ' " §§� _ Al a ? n ..-lI ,tarlr .tea. �. t..�”11.....4,. "., r '»S" ib^ F +,..� iru+ -%gi r 222' 'A a p Cv + . .5 � - '' i , J t {Ac ' 1 4; 4 rig ;1'..:111.0' , N .l:f l ,., ? ., '3 VI 4, ' 4f s`; ; q.*a ..,..v.,..4; 7:2„::,-:/:-., 5. ,v', § x ''kn. Rte,p 4 a.�,?, u.;'.: 'nt':s. .,. ... ,.,. ' ... Aggression/Cruelty to Animals 0 0 0 0 0 0 0 Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions 0 ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..I to this child. ': i 4+ ,; a9 v.* � .. .• « '§^'" •Yk :. '+'tF1Ax rta�Y :: "fir .- F �a 5n .2 ::.;:).b).: .t 3 a r I 7:7,7 -`, is£�,yN i y4 + t' *"..2',;:i P:3$7.: : te„ . vi-:::,‘..-,/....ali.k'5u' - ? • .,..L.'4,-.-:'u.m 3,C s 4,14+,,..„i ... • x Sac.fift..'`'r'titity �.'+a. 4;`,:na4t.' s`" e ua_. °1, ,i.15 a 'i: ; a 3 4 c _.(.i ". + ..:7; :. ,Yt Inappropriate Sexual Behavior 0 0 ❑ 0 ❑ 0 0 Disruptive Behavior ❑ 0 0 ❑ 0 ❑ 0 Delinquent Behavior ❑ 0 0 ❑ 0 0 0 Depressive-like Behavior ❑ 0 ❑ 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 ❑ 0 0 0 0 Eating Problems ❑ ❑ 0 0 0 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ 0 Requires Night Care ❑ ❑ ❑ 0 ❑ 0 ❑ Education ❑ 0 ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ 0 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 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 It, kr dtik. .Y§t ai,�;ak _ ii,t .�.iw ,tea Poe 0-10...$16.32/da $496/month County Basic N,I,1 A•e 11-14...$18.05/da $549/month Maintenance oti Rate A•e 15-21...$19.27/da $586/month) +Respite Care$.66/da ($20/month Aft $19.73 +$.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) ICI $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care Ei 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 spa, $30.25 day/$920 month(Includes Respite) (30 day max) VA 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 11/421 By ' �.I/�//. /. �7:i ri.'•^ 'a��-'� B . it Deputy clerk to they: Chai Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Gariepy, Susan J OF HUMAN SERVICES 5151 W 29th St#1706 Greeley, CO 80634 By. By: 6'--'mot Dire for By: 9 Weld County Addendum to the CWS-7A 1.WS-TA(KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 18 1. THIS CONTRACT AND AGREEMENT, made this date, I 01p/() by and betwe40II: ys the Board of Weld County Commissioners, sitting as the Bo of octal Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Garvey, Collin and Stewart-Garvey, Charlotte, Provider ID#1584953, 6766 St.Vrain Ranch Blvd, Firestone, CO 80504, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 a17/,--02/9 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 CWS-/A(KEU-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 WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN 1/42 SERVICES By � i / �. �� :��r=!��s, . ., (13Ll)C2) Deput clerk to the'`L Ch ir ignature ��►�'� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Garvey, Collin and Stewart-Garvey, Charlotte OF HUMAN SERVICES 6766 St. Vrain Ranch Blvd Firestone, CO 80504 By: B : Di ctor B . 3 ,7e)/Z, WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Garvey, Collin and Stewart-Garvey, Charlotte and the Weld County Department of Human Services for the period from July 1,2010 through June 30, 2011. The following provisions, made this I day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms t 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#1584953. 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 ❑1)One round trip a week 01%)2 round trips a week O2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week O3%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month O1%)Two times month ❑2)Three times a month O2%)Once a week O3)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a'/2 hour per day ❑1%) '/2 hour a day ❑2) 1 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 ❑1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) I I to 14 hours per week O 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? O 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%) 1 I to 15 hours per week ❑3) 16 to 20 per week ❑3%)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) DI)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one timeper 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 ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A . (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..I to this child. y 4 cv s. m 4t c ••/,tr 5 ', t pi K E:Th.S e 4 .. y - �. PM ' a.. ". "l VS .t ; £Y t y. i > 1 Yh t v E t`tat . ,{W k 4 �„ Altli...'”s r:Vt ..;� .R14 P$£�}i.:3 .� ,. .._>L tf..- .•,, a• c..... ,R a.:- ''AiScix u.C a..:: ; „ . ' ... . :4 §$' Aggression/Cruelty to Animals 0 ❑ ❑ ❑ 0 0 0 Verbal or Physical Threatening 0 ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 Cl 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 ❑ 0 Cl 0 0 ❑ 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child. '�+_ tv,.+ t .may T.4xk'. '.'''..r-L'.......: A: it '"k ;.. z,ivt yt2 7 t f f, 1 . - e d.'+. 2 � 4 A , � ti k S 5 ."f it •" ,"."('''''.i...',..,' tYY .. 9,� � 4 7wn� , 4 :n t .47,...c:':.-....':-..,;1•;.",-,'.'72;...,,-, ' r e *d. a �+ .. �+ °r Lx«c Y . r r z�,1a}} r t*a a:� x y�ya` 'rt `_ ,., Y"„' ..'.01 u '.. R^£.':/:J,"'6 ... .Td'...",PS; h:# ., :,. 7 L4:a .. a ` .:': ..i .. ... ...!,:e Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior 0 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 0 0 0 0 O 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 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑i ❑ 1'/z ❑ 2 ❑ 2A ❑ 3 ❑ 3'/ 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE !: 5 �} R}f L.. �� flS F L $ kYt tt d.i�• � �2'fi ��'f*��7:iL 4 d s It �P§ Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance 10.1 Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care go Total Rate= ($20.39 day/$620 month) kyla $23.01 1 1/2 +$.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 €,1 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 giTotal Rate=($40.11 day/$1220 month) Assessment/Emergency Rate irt4 $30.25 day/$920 month(Includes Respite) (30 day max) 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 1/42 By:41-Wi Deputy"Jerk to t �� ' �� Ch it Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Garvey, Collin and OF HUMAN SERVICES Stewart-Garvey, Charlotte 6766 St. Vrain Ranch Blvd Firestone, CO 80504 By By: ii ctor By: ao/n--ai9e 9 Weld County Addendum to the CWS-7A CWS-/A(KIU-IU/9Y) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, I 4011) by and between the Board of Weld County Commissioners, sifting as the Bo d o oc(al Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Gerardy, Jerry and Priscilla, Provider ID#1530549, 3408 Cody Ave, Evans, CO 80620, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 Serfs. ts- 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. -0 C 9. Not to release the child to anyone without prior authorization from the Department. Cr 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. I , CF%/L%- c /i LWS-/A 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 aft4r placement and give a copy of the completed form to the out-of-home provider. -� C Ca Ca 2 1,WJ-/A (KEU-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- - yy WELD COUNTY BOARD OF SOCIAL I R a�` SERVICES, ON BEHALF OF THE WELD /� -♦ ` U° COUNTY DEPARTMENT OF HUMAN �► �` :..1 '� •�� •��., B �I � ♦ flee / � 1)(vSERVICES .�p� ✓f+ _ Deputy' lerktot Chair ignature SEP 2 Approval as to Substance: :� PROVIDER 270`_ WELD COUNTY DEPARTMENT Gerardy, Jerry and Priscilla OF HUMAN SERVICES 3408 Cody Ave Evans, CO 80620 if cn crI BY: irector 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 Gerardy,Jerry and Priscilla and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this I day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms 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#1530549. 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 unproved format or inadequate documentation is provided,the County reserves the right to deny payment. D B. Be submitted by the 4th of each month following the month of service. gthe reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. ac/c- SR / 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 Hunan 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 part} 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,D 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. �= c_ B. Have not, within a three-year period of preceding this Agreement, been wnvicted of or had a civil judgment rendered against them for commission of frau&or a criminal offense in connection with obtaining, attempting to obtain, or pyforming a public (federal, state, or local) transaction or contract under a public tansaction; violation of federal or state antitrust statutes or commission of embezziAment, theft, forgery, bribery, falsification or destruction of records, making fine 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) ry Cp 13 CA cn 4 Weld County Addendum to the CWS-7A S-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 01)One round trip a week 011/2)2 round trips a week 02)3-4 round trips a week. ❑2'/z)5 round trips a week 03)6 round trips a week ❑3%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 01)Once a month ❑1%)Two times month 02)Three times a month ❑2Yz)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'/s hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 %z) 1'/z-2 hours per day 03)2'/:-3 hours per day ❑3'/) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week ❑1'/)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%z) 11 to 14 hours per week 0 3)Constant basis during awake hours ❑3%z)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/z)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%z) I 1 to 15 hours per week ❑3) 16 to 20 per week ❑3'/)21 or more hours per week Comments: A 1. How often is CPA/County case management required? (Does not include therapy) 73 ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) r= DI) Face-to-face contact one time per month with child and minimal crisis intervention. _O ❑1%z) Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. U ❑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. 031/2)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive N 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) ❑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 • (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'sly to this child. �5, a rria a-`''' ' N* rt : °'.'". #`d�t v`' �� u^ r .s, 'c f a. -:-.:,*:72:142:',0.:., . ..c # 5R ':.::„it $,p 'Aa. . * .'4a7."'PCS,''r-F;,,:t .u..?6h . '.rl+ �:-'b Cdri u:A.t.c4r, I' .� ats:'i'_':.ys .... .' ':. ' ,<. ., . .. .. Y•. .. .. i,"; 1.3: 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 Stealing ❑ ❑ ❑ ❑ ❑ 0 ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ 0 0 El Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ 0 ❑ 0 ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ 0 ❑ ❑ Runaway ❑ 0 ❑ ❑ ❑ ❑ ❑ c• Sexual Offenses Cl ❑ ❑ 0 ❑ ❑ ❑ a b O1 6 Weld County Addendum to the CWS-7P • (Exhibit B) WELD COUNTY DNS NEEDS BASED CARE • BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..l to this child mv"rt yww^ $ A1:74(/',•,.`ai . v'xcf,-H. , a'" p p' & c ' k"��•�y@PY y Y a'd nth*e 4n .:"•:..* `3/ T 24 �, +'`iy� t F 111�v'''ti.h.7gi: : ,44 k L +�'ISa'k •k. ,, a,} �474:11t pyN,Z• 4 11i L S t 4.' 4�R r. as ��. � n s, � ; � ��' 'e 9' '� n :' C .. ,., a,tr i '.M:m+: +r-rnt•.)s a^4ti "e.V. .4.':.,c,+:**S•.w t . . kaial.a..xx a_ x , .. .. . :1",..i.:. Inappropriate Sexual CI 0 CI 0 CIBehavior Disruptive Behavior ❑ ❑ 0 0 0 0 ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ 0 0 Depressive-like Behavior O 0 0 ❑ 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ 0 0 ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 ❑ ❑ 0 ❑ Eating Problems El ❑ 0 ❑ ❑ 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ o e__ r Education 0 ❑ ❑ ❑ ❑ ❑ ❑ D Involvement with Child's lti Family El ❑ ❑ ❑ ❑ ❑ 0 •n CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/2 ❑ 2 ❑ 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 � y apex Age 0-10...$16.32/day ($496/month) County Basic Aye 11-14...$18.05/da $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) $26.30 2 ir +$.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) owl Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) ;a P^ Effective 7/1/2008 r- -0 D fi Ca cn 8 Weld County Addendum to the C W S-7F 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 �- )BY: lL� 1aflèt 1 13y Deputy ' lerk to the '. ./f U.J, Chai Signature �•.�� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Gerardy, Jerry and Priscilla OF HUMAN SERVICES 3408 Cody Ave Evans, CO 80620 By: B ' Di•ector �I By: ti a D C- Cl „:21//-'- 2/96: 9 Weld County Addendum to the CWS-7A (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, 1 xO10 by and between the Board of Weld County Commissioners, sitting as the Boatel of cial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Gomez, Oswald and Christina, Provider ID#1588508, 7226 Matheson Dr., Fort Collins, CO 80525, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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-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 th- .�'P WELD COUNTY BOARD OF SOCIAL "❑'+�La SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: ; ; . :•. ' Deputy ' rk to the B�yy'�/uI' Chair ignatur . SO 202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Gomez, Oswald and Christina OF HUMAN SERVICES 7226 Matheson Dr. Fort Collins, CO 80525 By: By: ( .arey"/ D rector By ektii 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Gomez, Oswald and Christina and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this 1 day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms o the greement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1588508. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. 0V7Z) x04 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 S-7A C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (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 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'/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 ❑2)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 ❑2) 1 hour a day 02 %) 1'/:-2 hours per day 03)2'/z-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) I 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 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'/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. (Le.mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. O1%)Face-to-face contact one time per month with child and occasional crisis intervention. ❑2)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 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 ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7P • (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. tO �h l sZ:p ttiel , t a` h •• ^.t e& ,...-,,,4,2;.! ��+c ?4 s^ C .r",.4'C::01K."..."1," 'wta 't` $Y:#,.t • # ' .- •,- x,, "4 py4tY#°5 • t a �,: f s n , s:4 7, t r, g„.at '+ tq ? t. ttz fsf's t +r x SS "164:::::,:?(;;-:'":" �''{Fes :.:.2 1t a: q' ;, r tig':A't, ' . .:, r,�q �, tilt l¢�" m av .:..:. &4 � .x, �u� t?:n e .u.�a, ..:n : i° t�yi:,x 'rhk' t�e.&*��+•., .• .. ..•.. . . ,._. .t. t,a,., 3x! 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 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 ❑ 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..l to this child. Ff ;:i�'ai77:1:•§,uxa• 'tk , x y4- x., ' gg� r ". ' ;v• -A" , w • ': - �' '�k"3 " h• n h 4 *' • ., c''';',1''''-'-g': � g y Y iy, :.v.h�€?'"d '. gRpt P L y�i.�.. } . iti;; ' ; a:; t, 4:::::P.r. 'L yy' : & tl'4.?+ YR{. ‘S� M1 4. yk a��r '' s,� ` g 'r kv r ' t 4: vast + `" i ,p 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 Medical Needs (If condition is rated"severe", ❑ ❑ 0 ❑ 0 ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ ❑ ❑ 0 0 0 0 Boundary Issues ❑ o ❑ ❑ ❑ 0 0 Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ ❑ 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑I ❑ 1%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 `u i" •�s # • M1 A.e 0-10...$16.32/da $496/month bsia 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) $19.73 7 +$.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) Ats 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Al Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 tot C ... d WELD COUNTY BOARD OF SOCIAL 7.5 SERVICES, ON BEHALF OF THE WELD r � COUNTY DEPARTMENT OF HUMAN SERVICES By: , l / �� L�.L, $ : : �._a��,.44T Deputy 'erk to the :�y 14 C :it Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Gomez, Oswald and Christina OF HUMAN SERVICES 7226 Matheson Dr. Fort Collins, CO 80525 By: By. Dt ector By o?W/( - /9 9 Weld County Addendum to the CWS-7A C WS-/A(K1 U-1 U/99) . INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT MIR 41/ 1. THIS CONTRACT AND AGREEMENT, made this date, AUK b wen )� �/ (I b by and between the Board of Weld County Commissioners, sitting as the B rd Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Goodman, Bob and Katie, Provider ID#1552796, 8134 Louden Circle,Windsor, CO 80528, hereinafter called"Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 ac!/ a/9� L W J-/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 I�WS-/A(KIU-IU/YY) I I7 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 IFa1LO% COUNTY DEPARTMENT OF HUMAN • �� SERVICES By: Deputy I%erk to the CU ill. p1�� Ch la r i nature EP 2 0 2010 Approval as to Substance: �`�;r� PROVIDER WELD COUNTY DEPARTMENT Goodman, Bob and Katie OF HUMAN SERVICES 8134 Louden Circle Windsor, CO 80528 By: By: dt-( WV/ N� ` D're for t A�� By: 41.2.:e , you. 3 0W/if- 9/9 • WELD COUNTY ADDENDUM It U To that certain Individual Provider Contract for Purpose of Foster Care Q' /Q Services and Foster Care Facility Agreement(the "Agreement") between 'W//.�Q Goodman, Bob and Katie and the Weld County Department of Human Services for the period from July 1,2010 through June 30, 2011. The following provisions, made this t day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms o 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#1552796. 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 2/9— 9) 9, 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 • (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 O2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week O3%)7 round trips or more Comments: P 2. How 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 O2)Three times a month O2%)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 01)Less than a''/x hour per day 01%)%hour a day ❑2) 1 hour a day O2 %) 1'/r2 hours per day O3)2%z-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? 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 O2%) I Ito 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%) 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) ❑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 (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. " st d r2-. �� Via'. '-,,,,„�, r ., r ' �$ v44-4 i. r a y t Ica:,1 r 7;'- § xiS ? 1 ,aaa ;',-...,...4 ss s . 'M r ,k gaii:SZ .S,::;-. „-.::, s as *e s§_i�..,x7z...?.".. ..e.`tsPQ13 Vu*:. .i�.a, :. ,. x..-.,,: .,.,L. .. ,:- ._•. . _,.. ..{'.. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ 0 ❑ 0 ❑ ❑ 0 Destructive of Property/Fire Setting El 0 ❑ 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 ❑ 0 0 0 Enuresis/Encopresis ❑ 0 ❑ 0 0 0 0 Runaway ❑ 0 0 0 0 0 ❑ Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/mtenstty of conditions which create the need for services that a..1 to this child. � ,;St's 4 v4 +�'r .a . p ,y Ti.$ ` rt x, � 2'ks. tj�a� x¢'s r �' � 'd rvt�i+ t a - s �, as�+ v i..44--164%, � '. .,- ,. ,, i r' t"r,: ti: t L*+,a ,;' es„s yam.,. is , t ya,tv '`s !#n 5`} "4 k ie ro`5 z' t 4a a ,ay 's t 't t w ,'.� .• 11 "4:. 3 "t '-'...\-.--'.'11,71' 211:a { y. 4.tr.. x 4 4 .� . :. r ". psi y r4+'� +:�€ 4 # - ' '"h ,., . + , a _°i,�p $'��a'a. �' �� ``+�� 4 t a�5 �+ t ,�a � �� -� �'� �n d a + s t •, � :� 'a - : v.s: '"a 1`'+,.:, 1-V pad'+, ' 2. -..:: 'r k1`t,Y s �., W +Liz t�i`i"Irizt.natak.°.`.,: a$x'ui�k z't ee"�`,a.....� ;ire +-..,7:>:i..s.' t., �..x ..... ..'`s.t :::.).:?,..z.,,,‘ '.:;.a v... ,+:. �' r'r, Inappropriate Sexual Behavior ❑ 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior O 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", 0 ❑ 0 ❑ 0 0 ❑ please complete the Medically fragile NBC) Emancipation O 0 0 0 0 0 0 Eating Problems ❑ ❑ ❑ 0 0 0 0 Boundary Issues ❑ ❑ 0 0 0 0 0 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 ❑ PA [112 El 2V2 ill 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE PA Age 0-10...$16.32/day ($496/month) 114 County Basic Age 11-14...$18.05/day ($549/month) Maintenance kig Rate 7.4Age 15-21...$19.27/day ($586/month) ifPN +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care it!.;.11! Total Rate= ($20.39 day/$620 month) $23.01 1 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) esb $26.30 2 4.66 Respite Care 411 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) $36.16 3 1/2 +$.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) Nal Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 f #.4 E Lames COUNTY DEPARTMENT OF HUMAN SERVICES By: B Deputy! erk to the %�j Char � Signature i� .,... '� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Goodman, Bob and Katie OF HUMAN SERVICES 8134 Louden Circle Windsor, CO 80528 By: By: /ari (✓ ,/ lt.44-,/ Direct t By:telf- e- A �2rt c2i9 , 9 Weld County Addendum to the CWS-7A LWS-/A S-/A (1(10-10/99) 1 • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT Mlr1 a ! 9 pm 1. THIS CONTRACT AND AGREEMENT, made this date, I '2p/L) by anifbetwa the Board of Weld County Commissioners, sifting as the B rd Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Hays, Stephen Dale and Chantel, Provider ID#1587489, 229 4th Street, Fort Lupton, CO 80621, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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��lG -O2/`J� 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(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 : 1. .., WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD fi COUNTY DEPARTMENT OF HUMAN S VICES By: /�lin - ► l . Deputy i rk to the Chair Si natur (jy °� CEP 2 0 2010 Approval as to Substance: �� PROVIDER WELD COUNTY DEPARTMENT Hays, Stephen Dale and Chantel OF HUMAN SERVICES 229 4th Street Fort Lupton, CO 80621 �j By: By: CAAAAt // P T _" ( irector /f By: 1d _ _ D 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Hays, Stephen Dale and Chantel and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this l day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of e 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#1587489. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. Weld County Addendum to the CWS-7A C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s)to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 2 Weld County Addendum to the CWS-7A PROVIDER SHALL: 1. Attend or participate, if requested by the Department, in staffing a child's placement with the Service Utilization Unit. Provider shall be notified by County staff of the date and time of the review. 2. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. Cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 4. Have medical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 7. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public(federal, state, or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3 Weld County Addendum to the CWS-7A S-7A C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (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? O Basic Maint.)No participation required DI)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 '/,hour per day 01%) 1/2 hour a day ❑2) 1 hour a day 02 %) 1'/:-2 hours per day ❑3)2%-3 hours per day ❑3%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed 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 ❑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 ❑2'/) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week Comments: A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑I)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. ❑2' )Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7P • (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. xp i �`h a g, w� °' .�s �' � t➢ :1` 1`4t 1 d.a7 b '' :.m t k $ i as a) 4' -„,..‘14:.,,•!•-•.:;.,. ¢ w 2 'f �t ' 4:7 } w ' ' t r �r 4 ,y # § & yT 4 �fiC.', -..1 ��4 �F'•V4vL4{ .�4s t . ,5Fy � a�!$�8yt e`}� ,$ wly.-:3 g°., v ,�„ �� _ xt ;,,.G v-*�' r• ? @{?x. � u,, w w+ : 47w 44 i '' e n :-.3.;:".r:::•••.;-'...-.•• ' 't4 � "�"ati' + °� ',`�.++y��frfr,,..'' ''(''yi�,dlAi.1:`4. a ijr.: .M .� u' P ... a a ;. y ,, .. 4, `:"--i .cb u.4:;:l a4s � � t .'dxS_e crki...v''e'`entT,w f ao- .,.. ., e. l:ca.taa+ .ss e. £ �. ="v . t'.•""t , 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 0 Substance Abuse 0 0 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 Sexual Offenses ❑ ❑ ❑ 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/intensi of conditions which create the need for services that a..I to this child. 'it, 41,7 `i t' ."'kti774 f Frfi fi t'" R . .r :iii. iipii:iiik,y'-.. e �`"li.7 a ,l r,i "7 u rt`` 8 '"n a td&} t ° M1 e 4- e; ::::f./..„.... y VC) , .sw r . 2r t ,p.,'$v. 4 { --;h i�. . 'M1 4:. ?3#. ��.§`a,E�.'°z'-t' zm� .n: v.. a� i C a ,�gu. xt.�'`a � . Y s9rt 4 'ors S,-Ae t,rr*`a # v vT zia )a cv ice. : ,f vS :l y„yc yi": 4.a .^,a 'I.:A- M4' a g. ' .."; ',r -, krartiariBntiaii4a711..iitli t " rt ,,, ',•'cci:Via; ._. .> ..x ,..l _._. °° _.... .,. .",a ;',I.L. „, ....tas)s Inappropriate Sexual Behavior O O O O O O O Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ O O O O O Depressive-like Behavior ❑ ❑ O O O O O Medical Needs (If condition is rated"severe", O O O O O O O please complete the Medically fragile NBC) Emancipation ❑ O O O O O O Eating Problems ❑ ❑ ❑ ❑ ❑ O ❑ 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 ❑1 ❑ 11/2 ❑ 2 ❑ 2'% ❑ 3 ❑ 3% 7 Weld County Addendum to the CWS-7A S-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE a s . ' 2 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 ($586/month) 441 +Respite Care$.66/day ($20/month) $19.73 +$.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) enti vIT $36.16 3 112 +$.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 Rate Ve $30.25 day/$920 month(Includes Respite) (30 day max) :r,. Effective 7/1/2008 8 Weld County Addendum to the CWS-7/ IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD • COUNTY DEPARTMENT OF HUMAN SERVICES no By: /.ii ' ►.l� ' 1�✓ ,$) B . Deputy erk o WC'�� Chair ignature ♦`�_'I SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hays, Stephen Dale and Chantel OF HUMAN SERVICES 229 4th Street Fort Lupton, CO 80621 By: By: ON/49 /" it ctor j By: AL o2E7cn- a /96 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 AGREEMENT nun in 73 PM I: 04 1. THIS CONTRACT AND AGREEMENT, made this date, .?jiftlby and between the Board of Weld County Commissioners, sitting as the Board of Sthial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Heimer, Sara, Provider ID#1547292, 3000 W 19th St, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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-/A0KIU-111/959 i 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 thppoi y ppapert,�&9 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 `+ Lam% WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN t t` :1/42 SERVICES By: B . -euJpJ l Deputy irk to the Bo 61, r� Chair i nature Approval as to Substance: PROV DER SEP 2 0 2010 WELD COUNTY DEPARTMENT Heimer, Sara OF HUMAN SERVICES 3000 W 19th St Greeley, CO 80634 By: By: ClIA[L l/YYLC yr Dire or By: 3 • WELD COUNTY ADDENDUM To that certain Individual Provi ftrp;t fW Pli4gse of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Heimer, Sara and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this ( day of 2010, are added to the referenced Agreement. Except as modified hereby, all terms t 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#1547292. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. 0?:1A72—. /9 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. 7 9 23 PM 1' 05 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 nrecedin his4g ee {ent, had one or more a public transactions (federal, state, na) t i to 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;manse which most closely applies to this child. THE FOLLOWING SEVEN QUESTMSIN&W1SIUMJAr,,1fXCLUSIVE: 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 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'/z)Two times month O2)Three times a month ❑2%)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? 0 Basic Maint.)No educational requirements ❑1)Less than a'%hour per day ❑1'%) %z hour a day O2) I hour a day ❑2 ''/z) 1'/z-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 ❑1) Less than 5 hours per week 01%)5 to 7 hours per week O2)8 to 10 hours per week ❑2%) 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? 0 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) ❑l)Less than 4 hours per month ❑2)4-8 hours per month O3)9-12 hours per month 5 Weld County Addendum to the CWS-7i (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..1 to this child. x 1R a_.�'t t` Yi`.Y1 of uua Li rl,. iiisat :?' s p i,;, &� .. x...�.s.:mx*�.� aar.,e.�"tL«sea`w+s$ ;x , ` :5�x� :waw.s.m':..t �,s :,. . ,. , ,,. w .. .e,. ..w...,>a_,a,.. ,r:;, Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ 0 ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ 0 ❑ 0 0 0 0 Stealing ❑ ❑ ❑ ❑ 0 0 0 Self-injurious Behavior ❑ 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 0 Runaway ❑ 0 0 ❑ 0 0 0 Sexual Offenses ❑ ❑ 0 0 ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7. • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..l to thi•s •child `a +xi i; t.r n �`iiii'l''s$ `'a 's"t'-"#` §5 . ...v 4'�•^7TP, #, ,:L''',,,::+ '' `, h -'k,w t +S, su 1:1 +:.?"‘.1;1.D; A"s f§ _. L • ,', ..s r °'r ¢ A rfrit,a t 3.. -f. c .?.c, } § ts;: ..:, ar, f,7 '� rv1 .a+ 7.,-! 7 t ss rc ) ,e „t-`a c? ,{x' '. 4" diy.8'E"+.a°'TM''.e+A°r ykt:'t` ..'' s a . .•xa "4'v+`,is 1,yiye"i°' }'+;tom • y „; ` , ` .q, i,✓x a c S s i $+ s Ft� t,1. g1.t fY`� 1 ` '+ Y.. Yys .. t.�sa,, A + K.° a". `*.y gat t#", " # ';',?;;', 10'11'7-,'.-61.'-',„.}1 ',. ��5 e Fe { " a5a' 1 " e 4" ';'..,•:; p;.,,:,„? + m'� s ,,•, 4 „", ct .' 'i Y'� c " I* y^ 6t# s 3 . a.;:9k ro a , ,,. . , ss;, f Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ 0 0 ❑ 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe', ❑ ❑ 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 Requires Night Care ❑ 0 0 ❑ ❑ 0 0 Education ❑ ❑ 0 ❑ 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/4 ❑ 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 I1flL1CI1II!E .a.zn.ra Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate 01 Age 15-21...$19.27/day ($586/month) 4.4 +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care Am Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 !ta iMo +$.66 Respite Care Total Rate=($23.67 day/$720 month) wis $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 Will +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care 01 Total Rate=($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care Total Rate=($36.82 dayl$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Rate illy $30.25 day/$920 month(Includes Respite) at (30 day max) WI 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 211''MM If O?MY'i3UARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD s L��a COUNTY DEPARTMENT OF HUMAN SERVICES By: Deputy ' erk to they. \ ? � C air Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Heimer, Sara OF HUMAN SERVICES 3000 W 19th St Greeley, CO 80634 By. By: ` \.k„M �r Dire or By: 9 Weld County Addendum to the CWS-7A LWS-/A (ttI0-I0/W) i • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT . • 1. THIS CONTRACT AND AGREEMENT, made this date, 1 -1 0 —I C) by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Hernandez, Roberto and Margarita, Provider ID#1520297, 912 Elm Ct, Fort Lupton, CO 80621, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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. N 0 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 N the Colorado Department of Human Services. o 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 (-ANN-/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. 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 tot iy:r"„yam WELD COUNTY BOARD OF SOCIAL EL®`` SERVICES, ON BEHALF OF THE` COUNTY DEPARTMENT WELD OF HUMAN SERVICES 36 11/42 By: / �///L/ � i �1��. ./ae'i �� By 19 Deputy Prk to t�" -. -� / Chair Ignature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hernandez, Roberto and Margarita OF HUMAN SERVICES 912 Elm Ct Fort Lupton, CO 80621 By: - By: it ctor By: 3 /C%-c2/`1� WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Hernandez, Roberto and Margarita and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this I b day o0(.GtQ , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of the!Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1520297. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided,the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. 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 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 ❑}'/z)2 round trips a week 02)3-4 round trips a week. ❑2%z)5 round trips a week p��6 round trips a week ❑3'/z)7 round trips or more Comments: P 2. How often is the foster care provider required t participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 1)Once a month ❑1'/a)Two times month 02)Three times a month ❑2'/z)Once a week 03)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? 741:asic Maint.)No educational requirements 01)Less than a'/z hour per day 011/2) 1/2 hour a day ■2) 1 hour a day 02 %z) 1'/z-2 hours per day 03)2%z-3 hours per day ❑3'/z)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? asic Maint.)No special involvement needed O1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hou s 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? asic Maint.)0-2 hours per week ❑1)3 to 4 hours per weekBID 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 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 inte ent on. (i.e.mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/z)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 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? 00)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per molt) ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7t (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 -s ''� '7 r ;z to sit .£' u i et ax :, u:c a� 4 % inat� :', r , �4.µrd t'� r f s 't�A f >i fi 't` �".a . ,' % i. 1 ;3N 's� 971' i ''va* .ah::. ��'X+a `;gsr!. _ :3t & - :"33. °MSvm.�.�3'_ . ,_�_�.. . .. . �4. .2; a r.• .. , .a,: e�`'.,° 4 Aggression/Cruelty to Animals E ❑ 0 0 ❑ ❑ Verbal or Physical / Threatening V_J,( ❑ O O O O O Destructive of Property/Fire Setting ❑ 0 0 0 0 0 Stealing / 0 0 El El 0 0 Self-injurious Behavior / Substance Abuse / Presence of Psychiatric Symptoms/Conditions ❑ O O O O O Enuresis/Encopresis V o ❑ ❑ ❑ ❑ ❑ Runaway FY o ❑ 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS-7/ (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a.II to this child. $45i M \ %� Y 'nxry h Pc.} n 3y r t .''a+, Ir-, 7�t ;I:: 4s " v 7 ` a r t tr* a ''' s.e. '°lt„a vik. a 5 * _ v m _�xy k yr„ A a g : . ,' a..4,.. ,4',,c,:frss itd"> ',,,,.,. a .°a,`- a Q.: . - �.. " 'aS r tl9 fa:°{+s ci:'v._..�4^f:£2...}a v»4, ..u.r r,. .. . .,.e .e $5 Inappropriate Sexual •EJ ❑ 0 0 0 0 0 Behavior 1 Disruptive Behavior 0 0 0 0 0 0 Delinquent Behavior 0 0 0 0 0 0 Depressive-like Behavior Medical Needs hC6 aP/M� 3/4 t0- (If condition is rated"severe", ❑ 0 0 ❑ 0 0 Er/ anay�, „.- please complete the Medically fragile NBC) Emancipation 0 0 0 0 0 0 Eating Problems I 0 0 0 0 0 0 Boundary Issues 12/ 0 0 0 ❑ 0 0 Requires Night Care PI 0 0 0 ❑ 0 0 Education El/ 0 0 0 0 0 0 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 ❑ 1'/z ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'/ 7 Weld County Addendum to the CWS-7P (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 5F R-yya` F . 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) $19.73 kis 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) 41q- $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 31/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care is:tTotal Rate=($40.11 day/$1220 month) Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 Etta COUNTY DEPARTMENT OF HUMAN y o.• ��` SERVICES By: I%///� G. ��ti �' �'�r BYCI.,.k airi�C/h ,I'_ � Deputy ' erk to the 3 !Yy ` .�� C Signature , SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hernandez, Roberto and Margarita OF HUMAN SERVICES 912 Elm Ct Fort Lupton, CO 80621 By: By. 7" D•rfegif By:A ,j are-a/90 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 70/0 gut 16 pp 1. THIS CONTRACT AND AGREEMENT, made this date, ' — / V-2o l b by and VW/4S 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, 2010 and continue in force until June 30, 2011 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— a/9 ., L 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 cwa-/A(Kw-i HYY) 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 tit T?':'�� WELD COUNTY BOARD OF SOCIAL fi SERVICES, ON BEHALF OF THE WELD i COUNTY DEPARTMENT OF HUMAN SERVICES bizcs\lesaanneita-- Deputy r erk to the ?'R Chair ignature udv � SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hoel, Elizabeth OF HUMAN SERVICES 728 Glen Ayre St Dacono, CO 80514 _ D ' �/ /- ' By: By: 5 � a' `' 11-1L-it kEtorftt 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 Hoel, Elizabeth and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this /y day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms t 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#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. 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 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 (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 ❑2)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week ❑3'/x)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 02'A)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 ❑1%)'/ hour a day 02) 1 hour a day 02%) P/2-2 hours per day 03)21/2-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week O1%)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? 0 Basic Maint.)0-2 hours per week DI)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.) ❑l)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. ❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 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-7/ • (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. i' t F� a:Z. .n.,, iv,,,,r- , yr t� .. r " .`ti 3.. ": . 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 Substance Abuse ❑ ❑ ❑ 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis O 0 0 0 0 0 0 Runaway O 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7/ (Exhibit B) WELD COUNTY DHS • NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a.'I to this child. 6 E ' ; b i..:Y l.:!tt a aka;: 7T7cret is - � ^ � • � ' . : v `' £rHm:k#kx,x se Inappropriate Sexual Behavior CI O O O O O Disruptive Behavior ❑ O O O El O O Delinquent Behavior ❑ O O O O O O Depressive-like Behavior ❑ ❑ ❑ O O O O Medical Needs (If condition is rated"sere"ev , El ❑ ❑ O ❑ O O please complete the Medically fragile NBC) Emancipation ❑ ❑ O O O O O Eating Problems ❑ El O O O O O Boundary Issues ❑ ❑ ❑ O O O O Requires Night Care ❑ ❑ O ❑ ❑ O O Education El O O ❑ ❑ O O Involvement with Child's Family O El El CI El O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'/Z Weld County Addendum to the CWS-7, (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE .. $ v t'T••,v••im''• . °x, s` °'� '�� -s w e r t,, S il.*� 4 Pa } 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 $586/month +Res•rte Care$.66/datir $20/month $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 112 + . . Total Rate=$.66($23.67Respite day/$7Care20 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$,66 spite Care Total Rate=($3Re0.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=$ ($33.54day/$1020 month)aM $36.16 !_: 3 112 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month):::4 $39.45 TRCCF Drop Down +$.66 Respite Care fr Total Rate=($40.11 day/$1220 month) Assessm ent/Emergency Rate4,0 1,0 $30.25 day/$920 month(Includes Respite) (30 day max) 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 SERVICES By: �/i,,,., �. , ►-�i.:�,�%� —, Bye Deputy lerk to �T '� �' ' �,1 Chair Signature kW% SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hoel, Elizabeth OF HUMAN SERVICES 728 Glen Ayre St Dacono, CO 80514 By: By: Ste, aura"' {.Q L 7-1q-ia ector By: 9 Weld County Addendum to the CWS-7A I,WS-/A(K1U-1U/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND 77 (FOSTEE9R CARE pp�� FACILITY AGREEMENT 1. THIS CONTRACT0�NAGREEM�Nt, made this date, q /lug„ L- °. by and between the Board of Weld County Commissioners, sitting as the B rd Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Holmgren, David and Dawn, Provider ID#1522699, 1201 Hilltop Cir,Windsor, CO 80550- 3336, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 G W S-/A 1K 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. 77/p�+�,�, 12. To provide transportation to the child to enable the utilization of professions rAsesahen necessary. The amount of transportation to be provided will be agreed upon at plabntpd may be changed upon mutual agreement of the provider and the County Department, as / 1.2 recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 GWS-/A(K1U-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. N O 14. To provide notice of hearings. c_ Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. gE N ATTEST: Weld County Clerk to t WELD COUNTY BOARD OF SOCIAL Las SERVICES, ON BEHALF OF THE WELD i COUNTY DEPARTMENT OF HUMAN SERVICES By: Deput ler to the U Chair ignature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Holmgren, David and Dawn OF HUMAN SERVICES 1201 Hilltop Cir Windsor, CO 80550-3336 By. By: irector By: 3 &12/C-c9/9� 4 • WELD COUNTY ADDENDUM To that certain Individual Provider ContraciVr4trPse PNFpste Care Services and Foster Care Facility Agreement (the"Agreement") between Holmgren, David and Dawn and the Weld County Department of Human Services for the period from July 1,2010 through June 30, 2011. The following provisions, made this c7;13,day of , 2010, 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#1522699. 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,,,lait antjerrif fpartment 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 1 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. in JUL 23 PM 2 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-ye eq�ce n4 thislAgreement, had one or more public transactions (federal oca )thnAinated 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 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'/,)2 round trips a week O2)3-4 round trips a week. ❑2'/)5 round trips a week O3)6 round trips a week O3%)7 round trips or more 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 O2)Three times a month O2%)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 ''/z hour per day ❑1%) '/,hour a day O2) I hour a day O2 %) l''A-2 hours per day O3)2'/z-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 ❑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.) ❑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. 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 ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. z2d,2";'2;4:24-.',”.7.4%,,,a- tom l` vp .'/i i i ;,...,.4'.* .. ' A a.a„r T x; a ;; q • _ + �i. n s i ti s 't5a:", nt.: e Ba s ry "`'11, t 131 4 � t°4 .. s. t c C e{� #, s `a ,sh ),su + ,,,,,,,,:,!;4„,:::;;;;;;;;,. i ,pi 4 :. §.. �tl ; ic 'r r::41 _S x� +& Std": 37' a r f� +; C ' A.Ek�: .r";b�s>�..a N2:wiuL,d;..tak'�.. _�qe..'fix ,, ₹'r�'�$-a.. �� Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ El ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ 0 ❑ ❑ 0 0 0 Stealing ❑ 0 ❑ ❑ ❑ 0 0 Self-injurious Behavior ❑ ❑ 0 0 ❑ 0 0 Substance Abuse CI 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CO Please rate the behavior/intensi of conditions which create the rvices that a el to this child. s.. ' mi�#7'w{' ka T'�' +},, 's,+y +,"C, s� am $7 diti ac ,hi re ,,,..“:.:;....N.:::27,., r: ,x '4. ty ' as ti.ek.' f a a a + r,"x is t ab a. ,, H x ' `k �,' , �+s y ¢ 3 a z s v, 1 w r ` °f nit*? �: t �k� r '',, x. „:„, a ,,;;;.5:4.4.i„ r '*-vic. ' -.,3 du * � � r, �'* a � �' to s �.�e'' f}i i * �.4zx x s�,;.,..-tv,. [r ; :,,. ......,.....,. . ....2.. ...„,„,.„,,,,,,,,,,„,„„,„ �, �. a.�y �'. �, + i•,: u ti '*,.1;',7'.1!:.;,':',-. y W ' a.§z. La •,s sww� : ,�, v.`� . xp s.-• r%'f f+-'+ �. , h a 4 tea",, ' v+=s ;" :..aif:A;.4, > 3 a ,•Inappropriate Sexual Behavior ❑ El 0 0 0 0 Disruptive Behavior 0 0 0 0 0 0 0 Delinquent Behavior ❑ ❑ 0 0 0 0 0 Depressive-like Behavior ❑ ❑ ❑ 0 0 0 0 Medical Needs (If condition is rated"severe", O ❑ 0 0 0 ❑ 0 please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 ❑ Eating Problems ❑ ❑ 0 0 0 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ ❑ ❑ ❑ 0 0 0 Involvement with Child's Family ❑ 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 El l'/2 ❑ 2 ❑ 2'A ❑ 3 ❑ 31/2 7 Weld County Addendum to the CWS-7/ (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE e {jA 9 .54 5• ,; • s ' ;fix �� •��$rc_ Y � §{ iRYTM3 @$ r Ace 0-10...$16.32/da $496/month County Basic A.e 11-14...$18.05/da $549/month Maintenancekivc Rate 65 A.e 15-21...$19.27/da $586/month) +Res.ite Care$.66/da $20/month $19.73 1 +$.66 Respite Care xitut 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) $29.59 2 1/2 Vf4 +$.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 ttp $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) Effective 7/1/2008 8 Weld County Addendum to the CWS-7A • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. 2010 JUL 23 PM I: 12 ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL � ` SERVICES, ON BEHALF OF THE WELD L® s COUNTY DEPARTMENT OF HUMAN SERVICES iso Deputy " lerk to the B'%'��)(�'act 1 Ch it Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Holmgren, David and Dawn OF HUMAN SERVICES 1201 Hilltop Cir Windsor, CO 80550-3336 By: By: D ector By: ^{� £2/( - ; /9 9 Weld County Addendum to the CWS-7A LWJ-/A (KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT ?Mg Ann 12 m/2 1. THIS CONTRACT AND AGREEMENT, made this date, 1211216 by and between /$ 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, Hunt, Olen J and Nina, Provider ID#1503154, 631 50th Ave, Greeley, CO 80634-1247, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 ace --,2/94 I.WJ-/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-I U/99) 4. To give the provider a written record of the child's admission to the home at the time of placement. E 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 t. yr^ : WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES • By: aLIAC Deput!' er o the t .j ! � Chai gnature Approval as to Substance: PROVIDER SEP 2 0 2010 WELD COUNTY DEPARTMENT Hunt, Olen J and Nina OF HUMAN SERVICES 631 50th Ave Greeley, CO 80634-1 47 By: By: Di c or By: 3 &f/� - c/9 4 WELD COUNTY ADDENDUM 71712 AU To that certain Individual Provider Contract for Purpose of Foster Carl PiJ/2, is Services and Foster Care Facility Agreement (the "Agreement") between Hunt, Olen J and Nina and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this / day of , 2010, are added to the referenced Agreement. Except as modified hereby. all terms of t 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#1503154. 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. ,a7c/C-ail 9 1 Weld County Addendum to the CW 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 DNS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ['Basic Maint.)Less than one round trip a week DI)One round trip a week 01%)2 round trips a week ❑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? O Basic Maint.)No participation required ❑l)Once a month 01%)Two times month ❑2)Three times a month O2%)Once a week O3)Two times a week ❑3'/:)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1) Less than a''/2 hour per day ❑1'/:) %z hour a day O2) 1 hour a day O2 'A) 1'/z-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 ❑1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) 1 I to 14 hours per week ❑3)Constant basis during awake hours O3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond aee appropriate needs with feeding, bathing,grooming,physical, and/or occupational therapy? O 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 ❑2'/r) 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.) ❑I)Face-to-face contact one time per month with child and minimal crisis intervention. Di%)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. ❑3)Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/x)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. K+"r.. A '" the behavior/intensity inter y of,coItt tl¢'4 ,� ,, €ttt'7etu $ itt n b '.� i 1 r•t t , �.t.Pik t� s. :. '' y itt; t x*i� +�+t 3` 4 :�^ {.t`1P SAL .°i.u i s0.14 la s t r�4/:' "6 r x �' i'.. rt'''''' h , z .. ,.:3".,a4;;;44141447-...,.:' 0._ i 9't 44;....."4(4.„. p '':: A j,t;`#'''*.nr�, {': t x 4 t f • • '' y .a '' p 'a e 4 u S "7 f : ".. Y 'ice i'2S t as a 'ems , 4 Aggression/Cruelty to Animals 0 ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 El Presence of Psychiatric Symptoms/Conditions ❑ ❑ 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 • (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. , 4h by�,z t .Kd.5 t4 .'k fir. lI q > �#v,`m°"R f "k 6 W'v 4540:1+t�','"',, .v .,g ' "u 0.'4 d r �# + #° V r 1$ h l k 4 i,t a� ''-',',v.:Fe , ' `S a^- r: ), 4 s e ayF ., ara. j "^.� ,,, .. � m '' „ 3. 3. 4 ""y`9i 5'a d, # 'I' t kr 3 . vig epl Ia TY'_ S'}'5 t',:.. i'"s`4i t ,, , t .. r y �F _�' tst:-:-•a `. v t n`-,ay4.. w' ,+ .y.uS r * + �S'.@ v. ,'' � s x4x t .SEc .,, a c.v. "u vg Af- y i4v sI d 4 — a 'sa :24 �',$, 5°'i--7n z 't n, �€ ,,, „ .,�, ..t.f,,^:` 5 4 ,-;:r!F 4aF x '*#"r�'(r v. ' 'x ri Fir a 8ttitigk };�yv r ", £s r v x� �. °l- s LlVSjiall a" ,s,4 h ;}ur s '� ".fs ra` , ,t { � 4 -r fr Al t P._. 4 '.. a4"$$i�a :i vh �yf r iper' u� is " li sF +: Aga .. '. .,n` GY s°e£�`"A�..Hs... axf}�^hl'; '�,shF_^�i a #' .cz'.. d '.a a. 4t}w .n. . ...."fi'4 ..°. :.'. . ; . ,°xo-..,��C'ti s. Inappropriate Sexual Behavior 0 0 0 0 ❑ 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ ❑ 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ 0 0 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) 0 ❑1 ❑ 1'% El2 ❑ 2% III ❑ 3'/ Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE • 6� £� 3 h � �1a � Age 0-10...$16.32/day ($496/month) County Basic III A.e 11-14...$18.05/da $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) istwA $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) 0,52 $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) 141 $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) a,. Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 IE f � Lam COUNTY DEPARTMENT OF HUMAN y • �, ERVICES 36 4,70 At— Deputy erk lo the Bo) . C a�ure SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hunt, Olen J and Nina OF HUMAN SERVICES 631 50th Ave Greeley, CO 80634-1247 By: By: i ector By: ,3?0k7-a/9 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-imyv) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 1029 'O 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, Hymel, Chad and Tiffany, Provider ID#1540875, 1257 Red Mountain Dr, Longmont, CO 80501, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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-11)/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 to ,('� r� WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: i Deput ' lerk to the Chair S gnature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hymel, Chad and Tiffany OF HUMAN SERVICES 1257 Red Mountain Dr Longmont, CO 80501 By: By: 'rector B : 3 0.2(;Z-ai9� , WELD COUNTY ADDENDUM To that certain Individual Provider pntrt,5qr P rppsg�Rf Foster Care C-,,,, K kAg� `h�Services and Foster Care Facility Agreeme a ee ent") between Hymel, Chad and Tiffany and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this 2 a day of JL o , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of the 4reement 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#1540875. 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. afe- a/96. 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 ❑l)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 DI)Once a month 01%)Two times month ❑2)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'''A 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 01%)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 1 I to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond 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%) II to 15 hours per week ❑3) 16 to 20 per week ❑3%)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 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'A) Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS • NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavtorhntensit of conditions which create the need for services that a.it to this child. t' ,x is '11 + $6�(AI� �y - A is „ a ;9!..'W.:W d a • • .: x - . e.:... rt ��.va: d^�:R c .. .. ' .0 :.... .. .. ... ...... �:: ; n tai s A.e - '; st 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 ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 ❑ Substance Abuse O 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 ❑ 0 0 Runaway O 0 0 0 0 0 0 Sexual Offenses O 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of�cronditions which create the need for services that a..l to this child. r e ;'„v ri-lh ii'r t "x3.4:44 hx 5 r as ., ^ z •8 ,��ayY r i :I T''.".:2--d :. 4,t iT. �9 a � , � S 't y�,} =`. .erpi.L �+, "- . . .ait ,:i7afil zLiaf°r.`•S.......'... .. .a-.,.:s. . ,,..,.. t .' �, . . .. ..a"m.�.4 :a Inappropriate Sexual Behavior ❑ 0 0 ❑ 0 0 0 Disruptive Behavior ❑ ❑ 0 0 ❑ 0 0 Delinquent Behavior ❑ 0 0 ❑ 0 0 0 Depressive-like Behavior ❑ ❑ 0 0 0 0 0 Medical Needs (If condition is rated"severe", 0 ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 ❑ ❑ 0 ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ 0 ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/s ❑ 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 In'ItAcOntiroaiP_ d Y 2 lar`$ m 4 'S 1^M '. fug � 1( j �0.� 14 "4 } � 1 ; €ti f A 4 k_,"iftlS� [. -}a £ i�b mil44•:: :...1:;?!... 'ti~5z'vC . �;1p `, '" ..-uk ��,� wq * wm, :: (• .1 A.e 0-10...$16.32/da $496/month 'fliCounty Basic A.e 11-14...$18.05/da $549/month Maintenance In Rate liel, A.e 15-21...$19.27/da $586/month +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) ei $23.01 1 1/2Ill +$.66 Respite Care Total Rate=($23.67 day/$720 month) eiN IA $26.30 2As +$.66 Respite Care ti Total Rate=($26.96 day/$820 month) NM Ili $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) 7.1 $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care LiA Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) FAI Assessment/Emergency tiLl Rate tkr4 $30.25 day/$920 month(Includes Respite) (30 day max) astr Z 41 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 Ito By: Deput lerk to th `T�t Chat � Signature � SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Hymel, Chad and Tiffany OF HUMAN SERVICES 1257 Red Mountain Dr Longmont, CO 80501 By: By: erector B : oZ/ 9 Weld County Addendum to the CWS-7A C W S-/A(K I U-1 U/99) tr INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 7P'n JUL 26^PM 3 �'`��l �) 1. THIS CONTRACT AND AGREEMENT, made this (crate; (l l P .A1./It1 by and between the Board of Weld County Commissioners, sitting as the lardA Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department"and, Kniss, Kevin and Kelly, Provider ID#1524303, 13089 Marion Dr., Thornton, CO 80241-1936, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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. 1 079/(7--s-o9 LWJ-/A IKIU-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 WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES I is / By: / i/GGL, , +L�i(�L/ ,'t .�, > B . 4 ne, c„, azi.. / Deputy I�o the Board Chair i9 nature Approval as to Substance: PROVIDER SEP 2 0 2010 WELD COUNTY DEPARTMENT Kniss, Kevin and Kelly OF HUMAN SERVICES 13089 Marion Dr. Thornton, CO 80241-1936 %l By: By: irector By:, ' 3 Cvo- .9/9� 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, 2010 through June 30,2011. 11 The following provisions, made this.1 A day of t , 2010, are added to the referenced Agreement. Except as modified hereby, all terms f the Iskgreement 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. 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 , < , ,,4 Li vi,1Lv:Cc1 fit• i t,iir V'1Cyhc6 NEEDS BASED CARE ASSESSMENT {'r;.,y� 121t . 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 O1%)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 DI)Once a month O1%)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? ❑ Basic Maint.)No educational requirements O1)Less than a%hour per day O1%)%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 O1%)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: ,o.u.- 0i.ti('.(1 i.-) inGniiO/<'s� ton jliv)ui nu-,tc) 1*o. ,.-O.J " '.2._ rii ' 'J LC/11401(7,Y15C'V1 S(-‘.'yi=r,nti;Nd 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 111)3 to 4 hours per week O1%)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.) O1)Face-to-face contact one time per month with child and minimal crisis intervention. O1%)Face-to-face contact one time per month with child and occasional crisis intervention. i2) 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? pert/ ❑0)Not needed or provided by another source(i.e. Medicaid) Less than 4 hours per month ,4,,,Cr J \'7'I ❑2)4-8 hours per month �1)3)9-12 hours per month ✓" ;f11 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a 9 II to this child. Aggression/Cruelty to Animals d o ❑ O ❑ ❑ O Verbal or Physical Threatening O ❑ O O O IZI O Destructive of Property/Fire Setting O O O O O M O Stealing ❑ O O O O m O Self-injurious Behavior ❑ O ud ❑ ❑ O O Substance Abuse [if O O O O O O Presence of Psychiatric Symptoms/Conditions ❑ O O O O O d Enuresis/Encopresis O O M O O O O Runaway isil O O O O O O Sexual Offenses M ❑ Ai O O O O 6 Weld County Addendum to the CWS-7A S-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..l to this child. SI Inappropriate Sexual / //2ita-te LYJ Behavior 0 0 0 0 0 0 C'cA!Q111B Disruptive Behavior fr///0/4-, el" • ❑ ❑ ❑ ❑ ❑ ❑ d lu , Arian('it �r- , Delinquent Behavior di,)/Itn1'.a 4 i O 0 0 0 0 171 O vevizek mrr,, . Depressive-like Behavior ,:f1/1 ,4L( , ❑ 0 0 0 0 Ili O �>'!!'l/ et `. g!aalterca iii Medical Needs thr .mutts (If condition is rated"severe", ❑ g 0 ❑ 0 0 O yx cia/, f'.L.fu- please complete the Medically / fragile NBC) Me iS Jx dap Emancipation Eating Problems (fin ❑ ❑ 0 41 0 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ Ea 0 Requires Night Care ❑ ❑ 0 171 0 0 ❑ Education di :Ala//K ititer1&'A enl1nt 4i4sf Involvement with Child's ,��(( -" /-G�t2`/tei dee1e'rev Family IA ❑ ❑ ❑ ❑ ❑ ❑ ..aile' , `,rtc7`- no d CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1`/ ❑ 2 ❑ 2'% ❑ 3 ill3% 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE d 3 k �kF v; 3i;k y } ' A.e 0-10...$16.32/da $496/month County Basic A.e 11-14._$18.05/da $549/month Maintenance Rate Ase 15-21...$19.27/da $586/month >yss +Respite Care$.66/da $20/month $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 r +$.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 a +$.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) $39.45 4 TRCCF Drop Down ' +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Rate I' A $30.25 day/$920 month(Includes Respite) (30 day max) 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 Es Las COUNTY DEPARTMENT OF HUMAN SERVICES By. �//Let��!�.►f �r'� / � B ' Ql�i(/ Deputy 'lerk3. tj \ � n-Ctif Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Kniss, Kevin and Kelly OF HUMAN SERVICES 13089 Marion Dr. Thornton, CO 80241-1936 By: By: / { i ector By: o? - Q/9 ; 9 Weld County Addendum to the CWS-7A U W S-/A (K 1U-10/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, '1 ICI I D 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, Kohler, Christopher and Vance, Michelle, Provider ID#1556593, 3755 Golden Eagle Dr, Dacono, CO 80514-8505, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 D2(/( -- 19 1:w5-/A(KIU-10/99) f 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 LW5-/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 tot. a?A WELD COUNTY BOARD OF SOCIAL ��` SERVICES, ON BEHALF OF THE WELD 7-3 i a►; ' COUNTY DEPARTMENT OF HUMAN SERVICES i 3861 i f ;iO�=1 Dep P Clerk to the B Chair Si nature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Kohler, Christopher and Vance, Michelle OF HUMAN SERVICES 3755 Golden Eagle Dr Dacono, CO 80514-8505 I By: By: it 1_ irector By: 3 cQZ ka•-c,2/l(c WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Kohler, Christopher and Vance, Michelle and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this ?LI day of , 2010, 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#1556593. 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. d?C/C-a2/9e 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 • • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? asic Maint.)Less than one round trip a week ❑1)One round trip a week 01%)2 round trips a week O2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week O3%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? VB—asic Maint.)No participation required 01)Once a month 01%)Two times month O2)Three times a month O2%)Once a week ❑3)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? asic Maint.)No educational requirements O1)Less than a''/3 hour per day ❑1'/:) %x hour a day O2) 1 hour a day O2 %) 1'h-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? L yrsasic Maint.)No special involvement needed ❑l)Less than 5 hours per week O1%)5 to 7 hours per week O2)8 to 10 hours per week O2%) II to 14 hours per week ❑3)Constant basis during awake hours ❑3%:)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming, physical,and/or occupational therapy? l�nasic 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%:)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) SBasic 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) DI)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. 4 k . Aggression/Cruelty to �,,/ Animals E 0 ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ 0 0 0 0 Destructive of Property/Fire Setting V 0 0 0 0 0 0 Stealing 0 0 0 0 0 0 Self-injurious Behavior 1 ❑ 0 0 0 0 0 Substance Abuse 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ 0 0 ❑ Enuresis/Encopresis / ,C-J! 0 0 0 0 0 0 Runaway Er 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A S-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that al II to this child. Inappropriate Sexual I:17 Behavior © 0 0 0 0 0 0 Disruptive Behavior / E 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 0 please complete the Medically fragile NBC) Emancipation / Eating Problems `lam! 0 0 0 0 0 0 Boundary Issues / Requires Night Care V ❑ 0 0 0 0 0 Education ❑ 0 0 0 0 0 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 ❑ 1'2 ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE E5 wt ..w�` ; Age 0-10...$16.32/day ($496/month) County Basic Age y ($549/month) 11-14...$18.05/da 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 21/2 rr, +$.66 Respite Care Total Rate=($30.25 day/$920 month) u $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) (30 day max) 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 \La`s COUNTY DEPARTMENT OF HUMAN SERVICES By: Deputy lerk to the ha' Signature l(t ��..,.� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Kohler, Christopher and Vance, Michelle OF HUMAN SERVICES 3755 Golden Eagle Dr Dacono, CO 80514-8505 By: By: Di ctor By: E/C- 2 /,� 9 Weld County Addendum to the CWS-7A WS-/A(K IU-lU/99) 4 w INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT M > , 0/d O jut 1. THIS CONTRACT AND AGREEMENT, made this date, O� the Board of Weld County Commissioners, sitting as the B r / cq by and between i d 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, 2010 and continue in force until June 30, 2011 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 t KIU-1U/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. N 20. To keep such records as are necessary for audit purposes by state and federal personr*. The records shall document the type of care and the term during which care is provided for`ktch child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. cn 21. To maintain medical, dental and educational records for each child/youth and supply upilited information to the County Department. t 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 1K1 U-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. N 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. -D 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 ice'! T"'. WELD COUNTY BOARD OF SOCIAL • SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES i l.6i By Deput ' lerk to the;1y 'U14 Chair gnature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Maronek, Dennis and Patricia OF HUMAN SERVICES 4860 Eagle Crest Blvd Firestone, CO 80504 By: By: (0lZR•G.¢, lM (gl4 fte ire or te 91 2 �, By: A, �((�(.t.� 3 atre-oc/J 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 1,2010 through June 30, 2011. C=1 The following provisions, made this I day of , 2010, are added to the re rr-.• enced Agreement. Except as modified hereby, all terms o he greement remain unchanged. `_ rn GENERAL PROVISIONS -0 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',faced 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 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 stridg, 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 othi person not included in this Agreement. It is the express intention of the undersigyed 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. 0 7. No portion of this Agreement shall be deemed to constitute a waiver of any immnity 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. o 5. Attend all necessary school meetings and support any plan that is developed reg ing the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any-I/own or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. w 7. Maintain, access and review information weekly on the Foster Parents Internet llatabase 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) N O O C_ C 1 V 41 C N 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 01)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 ❑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 01)Less than a'/ hour per day 01%) 1/2 hour a 02) 1 hour a day 02 %) 1'/-2 hours per day 03)2'%-3 hours Sr;day ❑3'%z)More that 3 hours per day c_.. Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and m5{nitoring of time and/or activities and/or crisis management? D ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours pe4week ❑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 01)3 to 4 hours per week 01%)5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑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? 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 (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. e 1 4 z .. :. a " s� s: tae' - r eta' 4,1,1, h. '. . psi ;:? `°.,.s. ' " .. Aggression/Cruelty to Animals O O O O O O O Verbal or Physical Threatening O O O O O O O Destructive of Property/Fire Setting O O O O O O O Stealing ❑ O O O O O ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ O O O N Presence of Psychiatric 0 Symptoms/Conditions ❑ O O ❑ ❑ ❑ ❑ r C,, Enuresis/Encopresis -0 ❑ ❑ O O O O O w C N Runaway ❑ O O O O O ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7A (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.•`x'.6,'x+'4:;." "s ' ,� avat 1A add '�7x;ti.ii#..:p+y°6 ,a, #{. ;v `k'� gyp' ., -:-. .yx -d,4 iW Y 'V nu+{� .r,:.,,:....,-- f •Sr �;:LT! t4.q ;,...:7,,:„,,,j,„'. ,r 3 #' titifp 'aa 3l'+ata. i`ri,V. 1 .., _ �} r r 3, k s 1P,1:: g421: o- a 3, �333:::s. #gym;a' o-rx _ � ? 11 � ... � -'a....',n sS.��.h�,n.5x. ..�k.e _'�.,t^ xcas,:.• 3'; ,. „:,:.,,r. .. ..,1'...•:, ,�,e.' r"�'h%�� .^� �.w`'a' Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 O 0 0 Depressive-like Behavior ❑ ❑ 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ a r Eating Problems r ❑ ❑ ❑ 0 ❑ 0 0 W = Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ N Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 ❑ 0 0 ❑ 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1% ❑ 2 ❑ 2' ❑ 3 ❑ 3'/ 7 Weld County Addendum to the CWS-7A S-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE 'tai �! •x. .3 011 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 1/2 510 +$.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 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 410 4.66 Respite Care Total Rate=($33.54day/$1020 month) IWO0 $36.16 r, 31/2 4.66 Respite Care F Total Rate=($36.82 day/$1,120 month) _ 0J-1 4 $39.45 TRCCF Drop Down 4.66 Respite Care Total Rate=($40.11 day/$1220 month) W F IV Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 S i ` COUNTY DEPARTMENT OF HUMAN • ' SERVICES Lr �, ,,•, 1/42 By: Deputy rk to the Chi Signature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Maronek, Dennis and Patricia OF HUMAN SERVICES 4860 Eagle Crest Blvd Firestone, CO 80504 ,A4By: By: tt ti 1' t U/ti�Tk4 By: G C (in e� aCe 4,2/Cie 9 Weld County Addendum to the CWS-7A UWS-iA(K1U-I WYV) t , INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1010 ith wt. 19 ppl�yy 1. THIS CONTRACT AND AGREEMENT, made this date, 1 162 — IC by and £'tv1en30 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, 2010 and continue in force until June 30, 2011 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 ,&r/./7- /96 LWS-/A(KIU-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 l,W S-/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 cE. ` WELD COUNTY BOARD OF SOCIAL ®`` SERVICES, ON BEHALF OF THE WELD • COUNTY DEPARTMENT OF HUMAN 14O SERVICES t to (;��• By: Deputy •perk o the Chai S gnature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Martinez, Andrew and Jeanna OF HUMAN SERVICES 4404 Monte Cimone St Evans, CO 80620 By: By: irecto • , ` / / By: 3 WELD COUNTY ADDENDUM mm To that certain Individual Provider Contract for Purpose of T oste -vale Services and Foster Care Facility Agreement(the "Agreement") between 3© Martinez, Andrew and Jeanna and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this (n day of Ja I L , 2010, 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#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. 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 ' (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 011/2)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%)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? I /Basic Maint.)No participation required ❑l)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? yy tgl Basic Maint.)No educational requirements ❑1)Less than a ''/hour per day 01%) 'A hour a day 02) 1 hour a day 02 %) I'/-2 hours per day 03)2'/z-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1'/)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/z) 11 to 14 hours per week 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 ❑2'%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week Comments: A 1. How often is CPA/County case management required? (Does not include therapy) Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 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'/z)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. ❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. . **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 0)Not needed or provided by another source(i.e. Medicaid) ❑I)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/ (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi y of conditions which create the need for services that a..ly to this child. v u fg::',%111;4.1!•.$x'€1 11;k1 4 M'IX -T 't' ri £ t' #ir S1 at:. w x�e•IVC: d'vr f "' 1,R1:,° ',71V r ., S P: 47,41t10'.,. ` F " *' r3' 4.i.,.c,.4....,....„.....,,,..„,} ..,.n °mow.R+., _w.*:.,a., .., .,...4 ' Aggression/Cruelty to Animals tit' ❑ ❑ 0 0 0 0 Verbal or Physical ��al Threatening gi ❑ 0 0 0 0 0 Destructive of Property/Fire Setting 0 ❑ 0 0 0 0 Stealing [1 0 0 0 0 0 0 Self-injurious Behavior 14 0 0 0 0 0 0 Substance Abuse Presence of Psychiatric Symptoms/Conditions [fit ❑ 0 0 0 0 0 Enuresis/Encopresis !� 71 0 0 0 0 0 0 Runaway 14 0 0 0 0 0 0 Sexual Offenses IsA ❑ 0 ❑ 0 0 0 6 Weld County Addendum to the CWS-72 • (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. ^has ° n t` r -Sx aA t r frst''.'.i "'",1'....":,;:l"; �. :::,;:l:"::;l.,,,,,., ''' v 'Ye'�"�°ar' v a yg5`'' A a. r 3xY,, +.,,, ,t phr t I: . , . e titl'*�1x,,.s .5,t� � 9` � k d `� { ti 4t Y d b.� �. t� 4 t " $� t`S°du 5v' ; : ei,� m.; �y . t "iin.:?+p ?,yZ+4. 6s�ttr , .�pb st ve K y r a t s'xa t illtbigatt.a £ ...i ....'4sf 'z`: ': 3^5�'R �..�'£='1.?-ix,SiLneCT. 1 vd 2 .. 'Y `..:.. ^ �. ��+s4 ,.,. „s .u. k'.� Inappropriate Sexual �( Behavior q4 0 0 0 0 0 0 Disruptive Behavior IY 0 0 0 0 0 0 Delinquent Behavior ' 0 0 ❑ ❑ ❑ ❑ Depressive-like Behavior 1 0 0 0 ❑ 0 0 Medical Needs Of condition is rated"severe", IXI 0 0 0 ❑ ❑ 0 please complete the Medically fragile NBC) Emancipation N 0 0 0 0 ❑ 0 Eating Problems 0 0 0 0 0 0 Boundary Issues 14 ❑ 0 0 0 ❑ 0 Requires Night Care ❑ ❑ ❑ 0 ❑ 0 Education M 0 ❑ 0 0 ❑ 0 Involvement with Child's Family 0 110. ❑ ❑ ❑ 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ��]1 ❑ 1'/� ❑ 2 ❑ 2''/ El3 ❑ 3'/z 7 Weld County Addendum to the CWS-7e (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE dm + .a:':u .: s ,. f f .. j tW i I . JS e E t . tt (3. ; vxa 's .. e /i. �'F` �°td t 4 } 1 a t a- d 1..c.;-;::>;:......:.'.4::';::-. "4*` A.e 0-10...$16.32/da $496/month County Basic4 Age 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) 114 IPtiti el +Respite Care$.66/day ($20/month) Bat $19.73 1sfi +$.66 Respite Care Total Rate= ($20.39 day/$620 month) CCP $23.01 1 1/2 +$.66 Respite Care rilTotal Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care 0 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)eli $36.16 3 1/2 ri +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) IN 444 $39.45 TRCCF Drop Down +5.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Op Rate $30.25 day/$920 month(Includes Respite) (30 day max) tit Effective 7/1/2008 8 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to th-- : .rd WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES ,i(�y? o t61 It: ultt , By �%///�. � �J�:� 't�:�.y' .,� B n./lit� Deputy ;ferk to the B �q b�itt Ch r Signature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Martinez, Andrew and Jeanna OF HUMAN SERVICES 4404 Monte Cimone St Evans, CO 80620 By: By rector ' �} By �'l 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-10/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT `` ?P' t� Sit 29 1. THIS CONTRACT AND AGREEMENT, made this date,l\ I //cD by and b twee8 the Board of Weld County Commissioners, sitting as the oar of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Mauk,James and Harriett, Provider ID#1537621, 3620 Dilley Circle, Johnstown, CO 80534, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 ace-a/9 , I-WJ-/A tKIV-IU/99) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 L W S-/A(KW-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 the '• y WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES set By: BS1411/0riZger47 Deputy lerk to the: � y�f% �,� Chair Signature ♦��/ l ' SEP202010 Approval as to Substance: �.r•► PROVIDER WELD COUNTY DEPARTMENT Mauk, James and Harriett OF HUMAN SERVICES 3620 Dilley Circle Johnstown, CO 80534 By: By: irector By. 3 ,2C/D- 2/%lc WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Mauk,James and Harriett and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this /2 day of 2010, are added to the referenced Agreement. Except as modified hereby, all to of e 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#1537621. 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. ,a2(✓/7- 9/f� 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 • (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 Dl)One round trip a week ❑1'/z)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'/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 DI)Once a month ❑1%z)Two times month 02)Three times a month ❑2%z)Once a week 03)Two times a week 03%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a''/z hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 %) 1'/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 ❑I)Less than 5 hours per week ❑1'%)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 DI)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'/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.) DI)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00)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/ . (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the ed for services that a. to this child. rt � a .ne v5 y .1 's ...4::, t !z:itak4hL$� �� i a rim 5`.°u i t y y..4w. y a i., rx 4 a i yow `"+* i ` . : . '''' t k;• t ;ac�a+:. n a a,,.,� x. a,,,4s +yam a j " ,t`5 ° i c +`'` 'a2 y"5a ssIAS - 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 Self-injurious Behavior ❑ ❑ 0 El 0 0 0 Substance Abuse ❑ ❑ 0 El 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 n 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ 0 0 0 Runaway ❑ ❑ 0 ❑ 0 ❑ 0 Sexual Offenses ❑ El 0 0 0 0 0 6 Weld County Addendum to the CWS-7, (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that ar•rly to this child. t �-f,'ir 4'444 °ty`, `'w r',2 `sa`y.'x a "Wa "�' '.� * a'sss. ��"�J �a�� : +swt 1x " fLx}E* i a 4'�'�sCt- e �i� 7 r� rr ai i.tsglifhlitite'1431 Lfizrs'uWc .-yr. .. ..xt . ' ns°da.±: 5x • .va,hww �' . .. ._. x u„ Inappropriate Sexual Behavior ❑ ❑ O O O O O Disruptive Behavior ❑ ❑ ❑ ❑ O O O Delinquent Behavior ❑ ❑ ❑ O O O O Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ O O ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ O O O O El O Eating Problems ❑ ❑ ❑ O O O O Boundary Issues ❑ ❑ O O O O ❑ Requires Night Care ❑ O O O O O O Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family O O O O O O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑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 RATE TABLE � t� t t` J£�ffi ik vet Ji'e 1:42 � � � � � tl & qtl tl ° aS.'�Yy•.ky!? ydyr '• i .x94Ry 4'' `4 A•e 0-10...$16.32/da $496/month Bee County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate A•e 15-21...$19.27/da $586/month +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) VIM $23.01 1 112 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.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 a +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Pm Rate $30.25 day/$920 month(Includes Respite) (30 day max) Effective 7/1/2008 8 Weld County Addendum to the CWS-7 I 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 COUNTY DEPARTMENT OF HUMAN 1♦ p; �� SERVICES 1aJthk / inot 11 i�V mite By: Deputy '�'*erk to the 00141 > hair Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mauk, James and Harriett OF HUMAN SERVICES 3620 Dilley Circle Johnstown, CO 80534 By: By: ��✓ it ctor 9 B : 9 Weld County Addendum to the CWS-7A L W S-/A(K I U-I V/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1010 JUL 19 PH 1: 30 1. THIS CONTRACT AND AGREEMENT, made this date, tic)5/ia by and between the Board of Weld County Commissioners, sifting as the B and 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, 2010 and continue in force until June 30, 2011 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(KIV-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 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 th s WELD COUNTY BOARD OF SOCIAL La SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN [ pqi SERV CES rase (IV Deput ler to the B 141' C i i nature SEP 2 a 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT McCreery, James and Tammy OF HUMAN SERVICES 120 Maple Ave Eaton, CO 80615 / By: B 72/Y/c /Ma- "'' 2cQy / By: �Y2V1 � � 3 cgC/t- O21 5 � 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, 2010 through June 30,2011. The following provisions, made this/1-day of • , 2010, are added to the referenced Agreement. Except as modified hereby, all to 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#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. ac/C-�/9e 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 01)One round trip a week ❑1%:)2 round trips a week ❑2)3-4 round trips a week. ❑2'/x)5 round trips a week O3)6 round trips a week O3%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required DI)Once a month 01%)Two times month O2)Three times a month O2%)Once a week O3)Two times a week O3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements DI)Less than a'/ hour per day 01%)%hour a day ❑2) 1 hour a day O2 %) 1'/:-2 hours per day O3)2'/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 ❑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 ❑3'/n)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 ❑2'/) 11 to 15 hours per week ❑3) 16 to 20 per week O3%)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) DI)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%)Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) DI)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Am .. h.. st"— w ! kri Iry t ., �i x{ u,: ¢ ^r x r � tug 1 S si � �' dv� ' ��° �, .₹4 P4� �; l @ t 4 5F i5'.4 k �4+ f ex W rir " ° °,, lleTV#2`its w:4 t #a ,ri } t�' �S:.p '` X' '2j' t LfiiT4 •t R a 9 4{ 4 t' P �w.:,, r { P � ac Baud "4 '.'! Sv y5 S Y � 8 Yf'6 i.. Ra .9R a�.F X a } y, ° e:^rs4.a4 4 .tb. . .#a IG'xW:^..._ .. x 4 `Xe Aggression/Cruelty to Animals 0 ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ ❑ ❑ 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ 0 0 0 0 Enuresis/Encopresis ❑ ❑ 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..I to this child. {442" 1 k AZ.4t *: . m b y "�t'�''' a '5'9 a e 4 " �p.Y� ' yr ..r ,kt is�� *k t f •s sir t x.it ` a ¢ r�' 4 X� iAy, �s a ' �w `F. a . .., a r :a' v n is `t 4 7 °v', 3 ;,v, {fit. 4 .. Kic.t::... -f r.,* d _ 4C2 v Rop--sops ' 'a4 i.. a. Ana 't ',i''':. w"..z�z ,,... ,�.- ' .. .^.,.. . ....,....;..a Inappropriate Sexual u Behavior 0 0 ❑ 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ ❑ 0 El 0 0 0 Depressive-like Behavior ❑ 0 0 0 ❑ 0 0 Medical Needs (It condition is rated"severe', ❑ 0 ❑ ❑ 0 ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ El El El 0 ❑ 0 Boundary Issues El El El 0 0 0 0 • Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ ❑ El 0 ❑ 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/ ❑ 2 ❑ 2/ ❑ 3 ❑ 3'/ 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE �..� • {° p ' f4 ik u3 t ys TM xL} §.a 'l�a`,�••�. "Y�fa'�' �E,€5��'U6u�` �4' k..".� x A��,x.,e9 Ace 0-10...$16.32/da $496/month County Basic Ace 11-14...$18.05/da $549/month Maintenance Rate Ace 15-21...$19.27/de $586/month +Res.ite Care$.66/da $20/month $19.73 1ilfkg1"i +$.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 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) ALA 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) (30 day max) 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 IS LE% COUNTY DEPARTMENT OF HUMAN SERVICES BY ,�/////. �r1 ii.e..��.l� —�� BYt 7 / tirn. ) � Deput ler to the :�i� age / C ai Signature �i� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT McCreery, James and Tammy OF HUMAN SERVICES 120 Maple Ave Eaton, CO 80615 By: B • ✓J � rector By: 9 Weld County Addendum to the CWS-7A l-WJ-/A SKI U-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 cd/t7 by and between the Board of Weld County Commissioners, sitting as the B rd f 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, 2010 and continue in force until June 30, 2011 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(/r-o7/9 LW ,-/A t 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(KIU-lU/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 y',,�`' I_ I WELD COUNTY BOARD OF SOCIAL .,� ERVICES, ON BEHALF OF THE WELD • p� •OUNTY DEPARTMENT OF HUMAN ■ e'p- Ikt r A►)zs =� RVICES By: / ./r G/ a , ! .%viii!., a 7 Deputy -rk to the Board � � 7 hai gnature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT McGee, Donna OF HUMAN SERVICES 1649 31st Ave Greeley, CO 80634 By. By: itrnAIK.Lae irector By: 3 0714i/0-07i it 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, 2010 through June 30, 2011. The following provisions, made this l day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms o th 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 (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 01%)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? 0 Basic Maint.)No participation required ❑l)Once a month ❑1%)Two times month 02)Three times a month 02%)Once a week 03)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a''/z hour per day ❑1'%z)'%hour a day 02) I hour a day 02 '/z) 11/2-2 hours per day 03)2'/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 DI)Less than 5 hours per week DI%)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%z)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'%)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) ID 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 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 ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7, • • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a•sly to this child. i e Yf lici7iifA d yt w m' ova. . -��.,, t *4¢ `yz v y '', • '�' ,1 - zy y 3.�x :..; . q;n gar ,,rE. l'-'°-,.• i .; a I..' _ kit. l a 6a' ffIKim.`a" '4r,ms a vx ',ice₹. c,:A.:: .� •tv. t `- 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 El 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 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-71 S-71 ' (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 11I to this child. ' k• .'5 e`. rk�" 't ... k;17. tt''`.-a'e k '.M q;+u ?" x;.*a ;4{ 5rn7. 4 t ' }w . e " "y. :, ,'*m"7 y.;+' y yAgr i 'h tt .-;:t.-f,';h R i ;ry k a'1 t a ;A: 'i s xE xS -c � f:1., *a ?T‘.. -, stoma .. lni .,yy ytet 4y"-,i4�*s g�k t�� ,' ..q'�'" ,• { a, r ri {v"" 7t, -. . x;( f ,u fan ',tie, �.y''R i '-`•-' t. An1AY'$ ,,..."-,:c-,,, � g� }, • 5 3. . x.;, i_ � a t '�'�`.Ai.+id. �s"fikz',2�p£a'a.xi:e!�3�i.,.. ix�a,&�'Sd,,.t_' .,.. .,-. , , . .u.:- ... ✓... .. :......S „z-u.�u Inappropriate Sexual Behavior ❑ 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 Medical Needs (If condition is rated"severe", 0 ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ 0 0 0 0 0 Boundary Issues ❑ ❑ 0 0 0 0 ❑ Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 ❑ 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/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 Y° ot 5 4 t s h : P • F Age 0-10...$16.32/day ($496/month) County Basic Si41 A•e 11-14...$18.05/da $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 ,j +$.66 Respite Care Total Rate=($23.67 day/$720 month) O6. za e' $26.30 2 +$.66 Respite Care wit n, Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$.66 Respite Care tit 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 ffg $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency 7L Rate - $30.25 day/$920 month(Includes Respite) (30 day max) Effective 7/1/2008 8 Weld County Addendum to the CWS-7. IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES $61 I1/42 By: .�/� Y i �.,�'4 IA,14I' B y)J/41`. Deputy ' erk to the-L� Q � / • Cha i7 gnature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT McGee, Donna OF HUMAN SERVICES 1649 31st Ave Greeley, CO 80634 By: By: e � i ector By: o?C/D-a i9� 9 Weld County Addendum to the CWS-7A C WS-/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, E / ,2(7/O by and between the Board of Weld County Commissioners, sitting as the ar f Sbcial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Mellmen,Jeffrey and Letha, Provider ID/41547484, 352 Laurel Ave, Eaton, CO 80615, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. I 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 cw�-i v(KIU-!U/VV) 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 ty� :r�� WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD ' • ` �'' COUNTY DEPARTMENT OF HUMAN e i �� SERVICES 'i 0 . ,, By: 4 Deput Clerk'to the Boa= uu,._ t /Chair Si ature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mellmen, Jeffrey and Letha OF HUMAN SERVICES 352 Laurel Ave • Eaton, CO 80615 BY: 7 By: 0.4 a- Direct By: \Dt 3 a /L7c ?/2 • 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, 2010 through June 30, 2011. The following provisions, made this ( day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms f t 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#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. o?(in-2'9 Weld County Addendum to the CWS-7A C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 2 Weld County Addendum to the CWS-7A 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 (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 O1)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 iz3)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? 12(Basic Maint.)No educational requirements ❑1)Less than a'A hour per day 01%) '/z hour a day 02) I hour a day 02 ''/) 1'42 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 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 03%)Nighttime hours Comments: Znc(,i VItcxAj a %/«Y S'tyc(red Se/PISA/le '(a ftevent yje rl(0 ProbbMf 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. ❑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 ,p2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a''I to this child. ,., ex'i"�d* t+ s ' � gv' ;wxt4,r s -.a ' M, are v",P�:: L¢r is at A4 §'4'tr '1. yf % k ' s' e w7r av • 3"xa°, s ' t`s s s'g:x W.,:z.....,-<..-.:,,.3s xi s ' frx'. 0/3„; - +-exs s i i s.; .,dy t tili.:xv . " dt t,vi ,,,:i...:'.1/4,..,,:1,44..it.„,rev.i.:,-,...i...z.:..,;;;Ittt.--.:a2'z;yu 11 '. ',- , -, „-,,? ` s ty r .,Atv:B x b+ .,.'1>.,..,;: Pwt a ...„,,.4,,,.:,:r p ..i.. .....,� „o-x''+xM � 6 _ � .�...,4ji.. ..ka,�exki�k.d�..ER 4.,�sai«> ... a�.a ... ..dv � `": ...M1�L . .«.v:s'�Aka"* Aggression/Cruelty to Animals Ea ❑ 0 0 0 0 0 Verbal or Physical lW Threatening 154 ❑ 0 0 0 0 0 Destructive of FF''ll Property/Fire Setting [6 0 0 0 0 0 0 Stealing /` 0 0 0 0 0 0 Self-injurious Behavior Mj't« n�+on� Substance Abuse 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions b 0 0 0 0 0 0 Enuresis/Encopresis Runaway * 0 0 0 0 0 0 Sexual Offenses 0 0 0 0 0 0 Weld County Addendum to the CWS-7} ' (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 II to this child. d- rt „ d�" ii ' irr4"t , }s o s a { v .v ss F'rrh'fi , r, 4 t . t L i a t �i .� :7 y$'ti . '',?;:4:4 .Iro i} ''iv,. -?y e' y41, ,�d a M. e r 'ice i „c 'k'�`{ 4 kr,�i''yya • f` i :y+m o- x}.s *� x'' M:4; ii,. dig h� s tiff Gr'Irti .i 5w i4 .V SIWOrt:' 'dr4.r:':+. 'ry v �a'x" ;„� T ';Ax aa � v. ,n c w"':';;C'74:4 d fig- ,,"'ti _- T'.4"4-;',10411.13::. ed . ,i 7,;7:3 G '7¢p » act #",. m ::^t_`:� a.' r .' ...:.I' >�,K�.. . ,a .. ' ;,,c.;:i..,..t ;4: Inappropriate Sexual Behavior XIO 0 0 0 0 0 Disruptive Behavior Gia O 0 0 0 0 0 t Delinquent Behavior g 0 0 0 0 0 0 Depressive-like Behavior To 0 0 0 0 0 0 Medical Needs (If condition is rated"severe-', LSt ❑ ❑ ❑ ❑ ❑ 0 please complete the Medically fragile NBC) Emancipation 0 0 0 0 0 0 Eating Problems S+,l l (40140A)ol4M) Merl VP vM.1s Boundary Issues Ki 0 0 0 0 0 0 Requires Night Care V 0 0 0 0 0 0 Education ❑ V 0 0 0 0 0 Involvement with Child's Family 4 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'/2 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE q 4 f vegesaktisiskiatintiv Age 0-10...$16.32/day ($496/month) 44, County Basic PA. Age 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) 304 +Respite Care$.66/day ($20/month) $19.73 1 14' +$.66 Respite Care 45.1 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) cirk $29.59 2 1/2 4 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 C.12, +$.66 Respite Care fshri Total Rate=($33.54day/$1020 month) ptai $36.16 31/2 c +$.66 Respite Care 14 Total Rate=($36.82 day/$1,120 month) fi 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Pitil Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 COUNTY DEPARTMENT OF HUMAN • SERVICES By: am 442 Deputy ' lerk to the B% S/P�� / 'Ch 'r e^ Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mellmen, Jeffrey and Letha OF HUMAN SERVICES 352 Laurel Ave Eaton, CO 80615 By: By: I, %j 'rector By: `4' L,r n /111O--,k I C 9 Weld County Addendum to the CWS-7A LWJ-/AjKIU-IU/YY) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT MP jilt 1. THIS CONTRACT AND AGREEMENT, made this date, /(270/0 by and betweAf?' /4 the Board of Weld County Commissioners, sitting as the B rd 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, 2010 and continue in force until June 30, 2011 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 o2C/C)- c2/9 LWS-/A (K111-1U/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 (-,W5-/A(KIU-fU/99) 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk tot' �` WELD COUNTY BOARD OF SOCIAL ® SERVICES, ON BEHALF OF THE WELD 01; COUNTY DEPARTMENT OF HUMAN SERVICES 4111 e`er �I By' %/!L/ � 1��4��Lf._f' �, B a Depu , lerk to the B�i'ZJ ( ' Cha ignature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mena, David and Marie OF HUMAN SERVICES 2905 41st Ave Greeley, CO $063y • By: By! erector By: 3 c2C/O-07/9e WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Mena, David and Marie and the Weld County Department of Human Services for the period from July 1,2010 through June 30,2011. The following provisions, made this I day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms 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 IE0/1510691. 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. 0V/0— (9 /% Weld County Addendum to the CWS-7A • C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s)to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 2 Weld County Addendum to the CWS-7A PROVIDER SHALL: 1. Attend or participate, if requested by the Department, in staffing a child's placement with the Service Utilization Unit. Provider shall be notified by County staff of the date and time of the review. 2. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. Cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 4. Have medical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 7. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3 Weld County Addendum to the CWS-7A C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A • • (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 011/2)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'/I)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required DI)Once a month 01%)Two times month ❑2)Three times a month ❑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 ❑1)Less than a''/I hour per day 011/2) 1/2 hour a day ❑2) I hour a day 02 %I) 1'/r2 hours per day 03)2'h-3 hours per day ❑3'/n) 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 On Less than 5 hours per week ❑1/)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/x) 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 011/2)5 to 7 hours per week ❑2)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.) 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. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/I)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'A)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00)Not needed or provided by another source(i.e. Medicaid) ❑I)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. �.k,'i.n'^�'t x s + " 1m.*c.a,. .as , s y % Av:1;,::Vie - k - t` S,rit '` ' � k-.$ � a i;, � ''- y "''.' ,. .ti:tr.:232.....21.47,.:, .L s "` . ,,....0;.*...h,-*. S ,.:d �"'c.. ..; ,.. . ., , .,, .N. . .... .,.,_.. , ,...„; .: rid,. Aggression/Cruelty to Animals 0 ❑ ❑ ❑ 0 0 0 Verbal or Physical Threatening 0 0 ❑ 0 0 ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 ❑ 0 Stealing 0 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ 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 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ 0 6 Weld County Addendum to the CWS-7A (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,•.•I to this child. ; ,`` t :.. a .: f,, g x 7 �L' : eti ',mr f y't t S ,n _ . w. ;.x& °9R°kia,:,rw.. a .nt,, g,g...sAn k�w ?.4L ^`,(o- 4 1� S 4 ' , T '` ` v* `, » yY-:,r..y..'.1/24...17;iid "` o-n F 5: . 1. it al aikkirtgatiii 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 0 0 ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ ❑ ❑ ❑ 0 0 ❑ Education ❑ ❑ 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑i ❑ 11/2 ❑ 2 ❑ 24 ❑ 3 1113'A 7 Weld County Addendum to the CWS-7A S-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE f7 � !^�7'�u may, 't x- n �i�"k ' k ��`"�i"�v 4 3Sd�€; " S'i " F69 t Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate ;;.:41 Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) 4,142, $19.73 +$,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) gel $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) 41.0 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) (30 day max) 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 [L 4 COUNTY DEPARTMENT OF HUMAN SERVICES ` ;':`•sue• Depu ,'ler to the B n, Chair ignature `►--►�� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Mena, David and Marie OF HUMAN SERVICES 2905 41st Ave Greeley, CO 8„0634,! By: BYi% .. rector � - BY: `-I l ,A,, t 1 ',10 (52c/(7-- D2/67 9 Weld County Addendum to the CWS-7A UN/5-/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, ,- Q/Q by and between the Board of Weld County Commissioners, sitting as the B rd f 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, 2010 and continue in force until June 30, 2011 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-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/9V) 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 tt. WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN isel• ' •'"'• 1/41�1 SERVICES By: ,�!!tL/: �:.•� �i►!��S?�• ' ► :. a i►at :O -a, 'a/As /WV Depu. Cler to the B 1 (II ti �, Chair Si.nature •� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Middleton, Brian and Deborah OF HUMAN SERVICES 2418 W. 24th St Rd Greeley, CO 80634 By: By: [fit .k Dir ctor By: 3 o?r/D-• 62J9 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 1,2010 through June 30, 2011. The following provisions, made this l day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms f t 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. 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? 0Basic 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. ❑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 ❑19:)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 ❑1%) '/z hour a day 02) 1 hour a day 02 1/2) I'/:-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? O Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week ❑1'/z)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) I I to 14 hours per week ❑3)Constant basis during awake hours ❑3/)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ 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%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. ❑1'/z)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'/z)Face-to-face contact three timesper 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 (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. -i3, '. K$ mot. rt a u i.5 a., ,,- p- ¢ ry, u.: r wp A S 4` % c'° ' .,g':r' O ro s' }, „n"M.1-4.kro r '42'f/1 "CII...7.—:.1.:....:' i �>¢� R .e 4 y 'M ''.g."-;.} it N 4ts F .i v' 'S.: x fit .t1'w1, .t:yte F/JI s 'w, ' :j u'4I5 n a. S5R :44r, S.k � das yet 5�'§ h xj '..,....1.�t I^nS `% t �w y: 'y -f,',,,-, .! 8l,,---frA"�@ic t �° roj b•'r k k, %)--k -y' $ ' t, y ro '�. • *• 'fi ,A22 ; 4 �t'��4 x. . ': v z t x z ed ° 'o- � x x t,;:.„ '£ 1 °w t 7, „a 1*. '&.t X.° %';,r' ` may;# i$ ' ,`;Nz,Gtt A....'4,0.,...0,4.-i.,t Te21 Z.., ' i• :. .. It'a .�.dk1 .$x¢'��x r.,..§,".�t "�a=s$''�;'`�`�."*Y<'' 1$ �i,' :.,ra:�.:?l.;:i,,..rI-;.-.;;;...,., ..t< .. , ,. .. .x .' .v :.,-r..[aW Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ 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 Self-injurious Behavior ❑ ❑ 0 0 0 0 0 Substance Abuse ❑ ❑ ❑ ❑ 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 ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ 0 ❑ ❑ 6 Weld County Addendum to the CWS-7P (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED ! i Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. �'ti � �4� r„��ya S,£ 7 v r 77" F s e�s,x .! .. +LSa . ... � �,. l ...3;�� Iae :::,,,,4!....w,;'.�..:,'tea .. .tt,e''.iithh'§`$.""$sv.tr.; ,9. ... ., ., . .x . .. . . . t, Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ ❑ 0 0 ❑ 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems El ❑ ❑ 0 0 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ Cl 0 0 0 0 Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ 0 ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2% ❑ 3 ❑ 3% 7 Weld County Addendum to the C W S-7P (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE n a x P • Age 0-10...$16.32/day ($496/month) County Basic itth 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) cid $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) 441 ttaig $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) stkil $36.16 3 1/2bola +$.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) (30 day max) 12 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 • d WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD • COUNTY DEPARTMENT OF HUMAN ke SERVICES tol By: /�.�,..� ►.��•,,rli � .oD�, B . Deput ler to thel `� _1 C a Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Middleton, Brian and Deborah OF HUMAN SERVICES 2418 W. 24th St Rd Greeley, CO 80634 By: By. irecto By: c967(1- c/te, 9 Weld County Addendum to the CWS-7A LI,A/S-/A (KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1°jpus'y 411 '' 1. THIS CONTRACT AND AGREEMENT, made this date, ��l ...VA 31 by and betw en 3s 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, Montez,Joseph and Alexis, Provider ID#1582735, 3208 San Mateo Ave, Evans, CO 80620- 8925, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 07(i) - /`l G 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 LW5-/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 Clerk to WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES (,. Depu Cler to the •� � ( V `� Chair S gnature � SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Montez, Joseph and Alexis OF HUMAN SERVICES 3208 San Mateo Ave Evans, CO 80620-8925 By: By ,/��'/// /7 Directo By:, K� 3 ?r/L?- ≤!9e WELD COUNTY ADDENDUM 1(1//I C`y To that certain Individual Provider Contract for Purpose of Foster Care // Services and Foster Care Facility Agreement(the "Agreement") between 3-s Montez,Joseph and Alexis and the Weld County Department of Human Services for the period from July 1,2010 through June 30, 2011. The following provisions, made this 5.) day of S..,k' . , 2010, 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#1582735. 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>?D/D- / 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? O 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. 12'/2)5 round trips a week O3)6 round trips a week ❑3%2)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 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 ❑l)Less than a ''/2 hour per day 01%) %2 hour a day ❑2) 1 hour a day O2 %) 1'/2-2 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 ❑1)Less than 5 hours per week 01%)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? LI-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%)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.) B1) 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. 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%) 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? A )Not needed or provided by another source(i.e. Medicaid) 01)Less than 4 hours per month 2)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/intensi of conditions which create the need for services that as.1 to,this child. aKn a jr. :a a tr i ,; o, s- .'„.:2.7.:..':: .„i"..:.0': as p�'aa Lo a 's.€` , :2. ix� wr;� y, Aggression/Cruelty to Animals till ❑ ❑ 0 0 0 0 Verbal or Physical Threatening t4,+�• ❑ CI Ell 0 0 Destructive of Property/Fire Setting a 0 0 0 0 El 0 Stealing ti. ❑ 0 0 ❑ 0 ❑ Self-injurious Behavior El 0 0 0 0 0 Substance Abuse 0 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ty ❑ CI CI 0 0 Enuresis/Encopresis `F� q ❑ ❑ ❑ ❑ ❑ 0 Runaway 0 El ❑ ❑ ❑ ❑ 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7A (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..h to this child. x� ..,i.3. 't e v " it.r b t r t ➢ fi h a, n+ �w ^a- r ". �'• a " P Z x:re:•;....i a a �Py,, t .. t�+1� ` 5°:,, '� !, 3 . 'r , , su•.. inappropriate Sexual 0 ❑ 0 0 0 0 Behavior Disruptive Behavior S o ❑ ❑ ❑ ❑ ❑ Delinquent Behavior 4. O 0 0 0 0 0 Depressive-like Behavior q. O 0 ❑ 0 0 0 Medical Needs (If condition is rated"severe", I: ❑ ❑ ❑ 0 ❑ please complete the Medically fragile NBC) Emancipation g 0 0 ❑ 0 0 ❑ Eating Problems O ❑ 0 ❑ 0 0 Boundary Issues O 0 0 ❑ ❑ ❑ Requires Night Care O ❑ ❑ 0 0 0 Education iN ❑ ❑ ❑ ❑ 0 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 ❑ 1'/ ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'h 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE �- 1t� ' s'� y„ x -t°..%1( t Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance 4 40 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 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) figp $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 4.66 Respite Care Total Rate=($40 11 day/$1220 month) Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) 44,111 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 RV , BEH O T CS SEOUNTYICES DEPARTMENTON ALF OFF HHEUMANWELD SERVICES By. �i��'.� �. ►� ,, ,!J�t�' 1 B . t� Deput lerk to th�i � Chat Signature Walt SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Montez, Joseph and Alexis OF HUMAN SERVICES 3208 San Mateo Ave Evans, CO 80620-8925 By: By: / / irector By: 1`Ar,Mvc, a7El0., cRl j,� 9 Weld County Addendum to the CWS-7A UWJ-/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, iy_ 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, 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, 2010 and continue in force until June 30, 2011 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 GWS-/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 LANS-/AlK1U-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 WELD COUNTY BOARD OF SOCIAL i g �� /�y�, SERVICES, ON BEHALF OF THE WELD `�`` COUNTY DEPARTMENT OF HUMAN SERVICES 422 By: ,'� ` � /w !.. .`war' B 0mn4.W / Deputy r erk to the n nv Chair Signature SEP 2 0 2010 Approval as to Substance: �� PROVIDER WELD COUNTY DEPARTMENT Moore, Earl and Patricia OF HUMAN SERVICES 135 Poplar St Lochbuie, CO 80603 By By: Ce^-7" recto J! By:( 3 o7rYC-02/2, WELD COUNTY ADDENDUM • To that certain Individual Provider Contract for Purpose of Foste4 e Services and Foster Care Facility Agreement (the "Agreement") betwetlii Moore, Earl and Patricia 2� /J and the ' SB Weld County Department of Human Services for the period from July 1,2010 through June 30,2011. The following provisions, made this I'1 day of --3,1 , 2010, 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#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. 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 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 O1)One round trip a week O1%)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 O1)Once a month O1%)Two times month ❑2)Three times a month ❑2'/x)Once a week 03)Two times a week ❑3%)Three times a week or more Comments: Po3a4t CA.PP/1 Nvc1) 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'/) %z hour a day 02) 1 hour a day 02 %) 1'/2-2 hours per day 03)2'%-3 hours per day ❑3'/:)More that 3 hours per day Comments:0 ,5.r pp i7 QOttA. 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 03%)Nighttime hours Comments: OoSnt &PP/r AA' -4-1 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%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%)21 or more hours per week Comments: _ OpStlt CI—011 iv etc-, A I. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2/) Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. ❑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. 4J OS 10241f Amy ve 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 tt- o n l /?pp jou, 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.I 1 to this child. :.,..„..g24. t. , 4i� T"S,`�.9Gflv' � '.;T T x .t:t r. w WS}a+k �, 1,ik- ,:le y .�.„ �.c'�9.4 � S a s, 6 - § �'S c fir! '? � y' k •'d%ry .i'w 6gir'37r E Y* Y£ P t r I e ' M :„.7..i.„-{".. ., 3i rp4.t :P. Xw�r .1\41,t y :�. * r ,TF ,: 'gyp . . ,...�.rvx. ��. . -., -'r�`�s«�'.#�u ...?:x.�'G�2....!'. &.#tfxk' 4/41?-41Y).E:� ..��'.::. .... .°... .°�.'�i `�r. ..,{,.:�: �,'w: Aggression/Cruelty to Animals 0 ❑ ❑ 0 0 0 0 Verbal or Physical Threatening ❑ ❑ ❑ 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 ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 ❑ 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway O 0 0 0 0 0 0 Sexual Offenses O 0 0 0 0 0 0 A- cJLO- 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. yn y,,4y i c ,� y.� ‘K„-,-,-,;„,—..„," * Ys 1. s. • •w y nr s 'bc' Rs ,o- !,.ffi 't`,3 d t+; § i. pi,a ae ^yT'*a i ,n .4*w s ; kkyy t !a y 3 rs"LI`r ; �' . x s°,v nip , . v a `�lkoroik,�' #c w''.'.' apt -.7.: ,: r t f. T' a , . ...t - `� `t ; a m"'r t "f"* t viii �" :� j .._....,+ra'?,e Inappropriate Sexual Behavior 0 ❑ 0 ❑ 0 0 0 Disruptive Behavior ❑ 0 0 ❑ 0 0 0 Delinquent Behavior ❑ ❑ 0 ❑ ❑ 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ ❑ ❑ 0 0 ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ 0 ❑ ❑ Eating Problems ❑ ❑ ❑ 0 ❑ 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ 0 ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ 0 `1� 9.. CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: \‘::at 1 (check level of need) Ill0 ❑1 ❑ 1'/2 ❑ 2 ❑ 2'/2 ❑ 3 ❑ 3%2 \t:-. a 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE u b54snr x " R A•e 0-10...$16.32/da $496/month County Basic kir A•e 11-14...$18.05/da $549/month Maintenance Rate A•e 15-21...$19.27/de $586/month +Res•ite Care$.66/da $20/month $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) MAI $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 It2 +$.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 pri Rate $30.25 day/$920 month(Includes Respite) (30 day max) 141 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 t and WELD COUNTY BOARD OF SOCIAL SERV , BEHL O T COUNTYICES DEPARTMENTON AF OFF HUMANHEWELD SERVICES By i�%1/// i , ✓Q�r�. �? $ ;�,• i tette46Z) Deputy ' erk to the y :(J Chai Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Moore, Earl and Patricia OF HUMAN SERVICES 135 Poplar St Lochbuie, CO 80603 By: By: oe rector By: ficrwry,L, zincro-uL o?c/ -a/ y 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-lU/99) 4 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT MO JUL 19 pp I: 1. THIS CONTRACT AND AGREEMENT, made this date, / AO0 by and betwee 9 the Board of Weld County Commissioners, sitting as the r f 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, 2010 and continue in force until June 30, 2011 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(KIU-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 GWS-IA(KLU-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 �� 1 � WELD COUNTY BOARD OF SOCIAL ®,` SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN y Sjf ) Bv' Depu 'Clerk to the B ` �� Cha' ignature SEP 2 0 2010 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: /314-n--2-7 irector () By: 3 c9C/C -.9li6 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Parker, Brian and Beryldell and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this ) day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms t 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. 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 (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 ❑2)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week O 3%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 01)Once a month 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 ''/z hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) 1'/z-2 hours per day 03)2'/z-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1'/z)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week 0 3)Constant basis during awake hours ❑3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week 02)8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 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) ❑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 • (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.,54'144, _q ill01: ,t x 7 ' "h,!".,: F,' ry�pry o d x� x: r x ti 'aYsS •.'^X4 4 . Y � t d C' RE ' . .I Se a ' $� t$.wt,i'rg it4: .:t �,�+nk '� x .. .:, '"t 77 '; `x+14 a'1 i 'r ... w L rt t• 44 I #�# ,x 1t i Oro ; 3 .,§ 3, the 1 7n •t4- ' •':'•i r g .. F .,, '4'a't '"yrt.' X �s °r ' i°4, :� ' t" s •""'4 ,+`'r 'ww,','�g..^` s LS r.k k,�'t::10 t° 'y °{1 r n •• E' =..!"4:''i .1.:r1:".0 �a Av;�:c£ss a' r 4?z.:: t.s'S,° .. �° ._vef:'i> .,., ,. ` . c ,+..... •, a:R'u Aggression/Cruelty to Animals O ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 O O O 0 O 0 Destructive of Property/Fire Setting 0 0 O 0 0 0 0 Stealing ❑ O O O O 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ O O O O 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 O 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses O 0 O 0 0 O 0 6 Weld County Addendum to the CWS-7A • • (Exhibit B) WELD COUNTY DI-IS 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. t IS F fia" ' i, i !1,,, tt '^' _ Y �' g3 4i h , t +. r"fi. .44,,,:, >� �iligg 7 �a,'yr ii} �v'+�,�.� �*. :_:,,:e41.=:;•1a Iq': �a" �s t 14 yes hi011....'. '. aL �" tr ..� : . . �':" i≥wra.+ag°S:,4n ,..to .... _ _._.?.,. . . .r'�.`:m=.;. ;"5 Inappropriate Sexual 0 0 0 0 0 0 0 Behavior Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ ❑ ❑ 0 0 0 0 Depressive-like Behavior O 0 0 0 0 0 0 Medical Needs (If condition is rated"severe', ❑ ❑ 0 ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ 0 0 0 ❑ 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care O 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1 Yz 1112 El 2% ❑ 3 ❑ 3'/i 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE y�.r •�tat+x�1l� : ' 4 t Y, ) ti te' k4= ° . F '' § Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance 411 Rate HiiiAge 15-21...$19.27/day ($586/month) kal +Respite Care$.66/day ($20/month) $19.73 1 PO +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care ti Total Rate=($23.67 day/$720 month) BM $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) Para lrf.tif $29.59 2 1/2 +$.66 Respite Care iliq Total Rate=($30.25 day/$920 month) WS IS win $32.88 3 +$.66 Respite Care 1 Total Rate=($33.54day/$1020 month) $36.16 3 1/2 es +$.66 Respite Care Total Rate=($36.82 dayl$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) ill it Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 fi '�, Elide COUNTY DEPARTMENT OF HUMAN 1/ r SERVICES 1` "�•�1/42 By: Deputy lerk to the ''t•Cy u A /� it Signature �►.•�� SEP 2 0 2010 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: 'rector By: 9 Weld County Addendum to the CWS-7A WJ-/A(KIU-10/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1n/q im /9p� 1. THIS CONTRACT AND AGREEMENT, made this date, 0 & by and between 29 the Board of Weld County Commissioners, sitting as the o of ocial Services, on behalf of the Weld County Department of Human Services, herei after called "County Department" and, Paulsen, Larry and Helen, Provider ID#42268, 1939 Homestead Rd, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 5(•71 ---o216) , C WS-/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 k UWJ-/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 WELD COUNTY BOARD OF SOCIAL `� SERVICES, ON BEHALF OF THE WELD • �� COUNTY DEPARTMENT OF HUMAN SERVICES By: //I/ ii i �.� ��r�� 44 1,�, 1 c' eto eA Deput P lerk to the s?( 14 Chair ignature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Paulsen, Larry and Helen OF HUMAN SERVICES 1939 Homestead Rd Greeley, CO 80634 By: y: irector 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 Paulsen, Larry and Helen and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this /Cday of , 2010, are added to the referenced Agreement. Except as modified hereby, all term f t 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#42268. 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. ?ClP- a/2 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 (Exhibit B) WELD COUNTY DRS • NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑1)One round trip a week ❑1'/)2 round trips a week 02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week ❑31)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 ETIcOnce 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 O11Less than a''/2 hour per day 01%)1/2 hour a day ❑2) I hour a day 02 %) l'/r2 hours per day ❑3)2'/z-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? Basic Maint.)No special involvement needed 01) Less than 5 hours per week ❑1'/)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%x) II to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week 02) 8 to I0 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) ilfBasic 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? I0)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 behaviorhntenst of conditions which create the need for services that a..l to this child }+ „x"�'c r "2 a or/i t dd.iiaa; ! .x::a t a � X� a.'i'c' y t �, i^. i'8k "�7 s�s,� �-,$ �nn:::?.17.:i-'-'.. , � .4 E. ,q-ar .'+';"= a " ' y.v j ,w. + *'. t+##� .� > .y ,'".s�"` v" ,. 'I�_.�: ,:-. t4'f•9MbQFx :i5ie'f Y � a;.UtI . ,i<s ...;."t64... e.. .r b `Y "M.} Aggression/Cruelty to Animals ❑ 0 ❑ 0 0 0 Verbal or Physical Threatening if o ❑ 0 ❑ ❑ ❑ Destructive of Property/Fire Setting El ❑ 0 O O O Stealing El 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse Ki ❑ 0 0 0 0 ❑ Presence of Psychiatric Symptoms/Conditions 11 0 0 0 0 0 CI Enuresis/Encopresis ❑ 0 0 ❑ CI CI Runaway )( 0 CI Sexual Offenses ❑ ❑ 0 0 0 0 6 Weld County Addendum to the CWS-7A S-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED },� Please rate the behavior/intensi of conditions which create the need for services that a..l to this child. " is v'g 5,,,.*'�'` 'h' `.t'� a�,..... v a imp r„t$x , v a ti� mv- }nY' X � d e xi5k wyz ias �"X'�` s "" s } ; # tx v s,r,,v 'T: x fit'- V:4 `' s-34 •y l "' 's §a 'rt i' r , , . i . , :C14, ,5..:011. 4'-...1 1?:57 a s ekdu :r '3 es r .' x` iiI' :t, v 'e3i -.t Y kk� y 5 .,1:, Q . 'kr _x... . ':kxS G.h. Nk hl �'�.a,..`... .1 . 'F z.. ex.. , i!$cry .h.. �.3. `rxi zws. t: Inappropriate Sexual Behavior O O O 0 0 0 Disruptive Behavior 0 0 0 0 0 0 Delinquent Behavior L" ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior fr o ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe ❑ 0 0 ❑ 0 0 please complete the Medically fragile NBC) Emancipation V 0 0 0 0 0 0 Eating Problems 1 ❑ 0 0 ❑ ❑ ❑ Boundary Issues 9' El ❑ 0 0 0 Requires Night Care 42! Education RO O O O O ❑ Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LE V L OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑1 ❑ 1'/z ❑ 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 c �� . Fh �}{ ii 4E . Mt! Age 0-10...$16.32/day ($496/month) County Basic ptiyiAge 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) ret $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1(2 irth +$.66 Respite Care Total Rate=($23.67 day/$720 month) ikAti $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)144:::::;:t7'‘ $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) (30 day max) Effective 7/1/2008 8 Weld County Addendum to the CWS-7A + f . IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN ILA SERVICES Sol Deputy.rerk to the C air Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Paulsen, Larry and Helen OF HUMAN SERVICES 1939 Homestead Rd Greeley, CO 80634 By: By: 'rector By: 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 moo lvpy 1. THIS CONTRACT AND AGREEMENT, made this date, 7--/V-/e7 by and betweien?/ 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, 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, 2010 and continue in force until June 30, 2011 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 y y /9/ 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 L W S-I 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 y� '� WELD COUNTY BOARD OF SOCIAL a' SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN 'R ^^�,,�', SERVICES iiiiItelH, Deput Cler to the :?••�► �, ` Char gnature ►.��' SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pierce, Kris and Larry OF HUMAN SERVICES 3017 54th Ave Greeley CO 80634 By: ft By: O( �.C�-•¢� irector By: Q-9�r� 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of FBS't7/��n oCa'r9 Services and Foster Care Facility Agreement (the "Agreement") between /: 31 Pierce, Kris and Larry and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this /y day of .mow/y , 2010, 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. & /(F- a/ /- Weld County Addendum to the CWS-7A C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. 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 01)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 DI)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 ❑I)Less than a'''A hour per day 011/2)'A hour a day ❑2) 1 hour a day 02 1/2) 1'/a-2 hours per day 03)2'/x-3 hours per day ❑3'A)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 ❑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 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.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. ❑l''A) 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. Ti. 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 (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. �.. t �':4re- 0 ,�"cs v�p �'�+""Y. a ? .t'k�at,� t� pp��' s- oe�4 a"e$rat .t*s5. ,0..,,,,,..c, „,:::,.,. ..,,;,,0„ k � x�. : e ai ,arnir 'w tir€`A v'`i'�*�� uxi �'�r � �,t .l 4 !„ �.4. +r �k r'w,� , �fi'�': ERij,. 4 v t„ ti 4ya .. } + Aggression/Cruelty to Animals ❑ 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ 0 0 0 0 0 • Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7P (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..l to this child. TI g $y t Y .ry4. "� � �, �'Y�'4 "�v'"'t+:vPv�F 5 `4h �� IS*..Sdt t 3. v4 '4#a A" " .y,' w A �S". ,M ii iaect2 ti. 'fi t g u aY.' h. .� 6 s& a.� sws"c ri t t o "° " �4`"` ` ;7,,% i' x t + v " r'vk=€t^`, t+ ,� 754:1: e` 3,� ` 'F z �' g ' .�, ° ;:i.`� r,..m* 1�: °a'4spy '11 ?^� .i.x ₹'7 -.; ,, s ��346O;;1:a y,, .� iq iti y, .4. 'fie-}; 1:--,',.....-;. /.., c : d a, shy".+. a', .y.,{§ a y, ppSq. . �,�. ,s '"„, =d " ? ,.�.. „'. ,. ,p�. '5 .. irv.«4.w. . Cam . �.__�'`�'... F' 'a '�. §:�,._++�.�A:�e'.�.,.a.tgy"M",w�P^i,..zri�"at-sCr'��.s �'A�k° .tr.ca..s .. ..r :. i",,.... .x� Inappropriate Sexual Behavior 0 ❑ 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 ❑ 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ 0 ❑ 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ 0 ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ 0 0 Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ 0 ❑ ❑ 0 0 0 Requires Night Care ❑ ❑ ❑ 0 0 0 0 Education ❑ 0 0 ❑ 0 0 ❑ Involvement with Child's Family O O ❑ 0 ❑ 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2'/s ❑ 3 ❑ 3V2 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE x i . r ,s s rr-, ' � � ,, �, Vie t v ,t . ate * 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 iiirt Total Rate= ($20.39 day/$620 month) LA $23.01 1 1/2 44.4 +$_66 Respite Care Total Rate=($23.67 day/$720 month) 44 $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) tr $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 igs 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 pl, ,sE $30.25 day/$920 month(Includes Respite) (30 day max) 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 Cler •rg oard WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: ,i' / �. ��lr��yX � ..� By. De put Clerk to t�a:��!4`, p � Chair Si ture SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pierce, Kris and Larry OF HUMAN SERVICES 3017 54th Ave Greeley CO 80634 By: . By: rector BY: / d• ft/c_ 9 Weld County Addendum to the CWS-7A L WS-/A(KW-IU/9 ) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT ?itifir• 1. THIS CONTRACT AND AGREEMENT, made this date, J1 ,I 02010 by 4tyren the Board of Weld County Commissioners, sitting as the Bo rd 666{{{ dcial Services, on behal{ 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, 2010 and continue in force until June 30, 2011 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 LW5-/A(KIU-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 L WS-/A(KIU-IU/99) 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to ``tdL a` WELD COUNTY BOARD OF SOCIAL ® ` SERVICES, ON BEHALF OF THE WELD r COUNTY DEPARTMENT OF HUMAN SERVICES eani Jar-- Deputy ' erk o the :� /Chair ig ature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pluma, Mike and Annette OF HUMAN SERVICES PO Box 34 Kersey, CO 80644 By: BY: 'rector By:6,./124-1•A 3 o?(/L)- (77/7 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 Weld County Department of Human Services for the period from July 1,2010 through June 30, 2011. The following provisions, made this day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms t Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#35126. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. j 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 ❑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? O Basic Maint.)No participation required ❑1)Once a month ❑I'/)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 of special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a''/2 hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) 1'/r2 hours per day 03)2'/z-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.)No special involvement needed DI)Less than 5 hours per week ❑1'%)5 to 7 hours per week ❑2)8 to 10 hours per week 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 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 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. ❑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) 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- . (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 'W.a '"tl n r4"sp+r" '''t'•4 r ay :g f4, 1: .$ ,!sv < a a.�k ra tl"%� 4kt" �'".^° St 's;A + kax� i t d i '( .u... 'C `°w � �x§.8 k v j,S, it.* be 4�dL1'v::s. .N3S?}a5'ffi. '�•b by Y'Nt ta.' .-nri 1442— ' €�14 ..Y-c,a' ,�l • '.V#t.:14 „:A l"a x ... at` iI,1 .SS 'k ti 844 1;:,: ..::-.41..w?. A v ,-;?.;. .9t, mt.. z n .. . : +r sat�udc 'i° t : {1. . .. .. .1. .:....... ' .. .k . ::::.,.2.' ...w .. -7-'114, cieu Aggression/Cruelty to Animals ❑ ❑ 0 ❑ ❑ 0 0 Verbal or Physical Threatening 0 ❑ ❑ ❑ 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 ❑ Stealing ❑ ❑ ❑ 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 ❑ ❑ ❑ 0 0 0 ❑ Runaway ❑ 0 ❑ 0 ❑ 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY OHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that al 81 to this child. '.;!...-....":;:!)-$7:..i'5.. ;s. •+_'=`s yr�Fk;c x '.t "I ' z z' i {. a A a'S£4x�I '' }k4.34Yti.kk:.•u7: '..5 AyJ ik9Gdffii -L9,�w'` h.? 4` .....its,,..: 4 }� -"`'v:".... .,. x� r- •ism 4i" „ ty, a *a $ y° -.,; !:- , �'�_. 2F s t₹� �� h'�a 3 ,��,t� a e . i ' 's u^s. . � � �. � t � .:� k�..s:43".:.s.'1s3.. r: '�..x" ka rx..x .6v.. ..., ,;. —.....1.4' :. . '. .°r. .x ..;:“.1."::,..'.. Inappropriate Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 El El 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ El ❑ 0 0 0 0 Medical Needs (If condition is rated"severe', El ❑ ❑ ❑ ❑ ❑ El please complete the Medically fragile NBC) Emancipation ❑ El El 0 0 El O Eating Problems ❑ 0 0 0 0 ❑ 0 Boundary Issues ❑ 0 ❑ 0 0 0 0 Requires Night Care ❑ El El El ❑ El ❑ • Education ❑ ❑ El El El El El Involvement with Child's Family ❑ ❑ 0 El El ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1%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 i 37 '{ i�T?w ', _.., ;.,. ₹ tier Tx � t t .' Y c 7• :i ;;,;.;••••r '+ '' ( 6v �� F rvtx ij � 1 � I i .ii,; •Y iy 4. .A 'C ryi Vui 4 s •$ayy{it rr axe Age 0-10...$16.32/day ($496/month) County Basic A•e 11-14...$18.05/da $549/month Maintenance Rate hitAge 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) Ilp $19.73 1 214 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) 491 $23.01 1 1/2 ta +$.66 Respite Care ON litil Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care IV Total Rate=($26.96 day/$820 month) ttii $29.59 2 1/2 +$.66 Respite Care 14,9 ill Total Rate=($30.25 day/$920 month) KJ $32.88 3 +$.66 Respite Care leTotal Rate=($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care In Total Rate=($36.82 day/$1,120 month) la 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) ss Ns Assessment/Emergency Rate 4xe', $30.25 day/$920 month(Includes Respite) (30 day max) "a 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 Cle irfl' d WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD •�•� #; =, COUNTY DEPARTMENT OF HUMAN SERVICES 1O1 /: By: � /L/ i , �,/ice ��:iC�� BY Deput lerk to the : rs� Ch it Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Pluma, Mike and Annette OF HUMAN SERVICES PO Box 34 Kersey, CO 80644 By. By: 'rector By: et�� C /1 07/9� 9 Weld County Addendum to the CWS-7A I,WJ-in(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, 4ths, I "(kW, by and between the Board of Weld County Commissioners, sitting as the Bo td SociA 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, 2010 and continue in force until June 30, 2011 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-wivy) 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-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 t�> �� WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN Ø1t i SERVICES rkir/i' B : Depu Clefk to the Boar.% `J ' Chair Sig ature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Ramos, Julian OF HUMAN SERVICES 2029 17th St Greeley, CO 80631 By: irector By: 3 c2C/(2 - 7/9,< WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the"Agreement") between Ramos, Julian and the Weld County Department of Human Services for the period from July 1,2010 through June 30, 2011. The following provisions, made this ( day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms t 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#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. 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 01)One round trip a week 01%)2 round trips a week O2)3-4 round trips a week. ❑2%)5 round trips a week O3)6 round trips a week O3%)7 round trips or more 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 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) I hour a day O2 %) 1'/:-2 hours per day O3)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 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%)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. 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? DO)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 (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/mtensi of conditions which create the need for services that a..l to this child. } 9 yk� is 4' hj L $ 'a Xy _Sa,,,ai. : 4�r 1 ...,-;.,@..:-.", fy --„:.v.-.7 Aggression/Cruelty to Animals 0 0 0 0 0 0 0 Verbal or Physical Threatening 0 0 0 0 0 ❑ El Destructive of Property/Fire Setting ❑ 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 0 Presence of Psychiatric Symptoms/Conditions ❑ El El El ❑ El ❑ Enuresis/Encopresis El ❑ ❑ El 0 ❑ El Runaway El ❑ ❑ El ❑ El 0 Sexual Offenses ❑ El ❑ El ❑ 0 El 6 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/mtensit of cond bons which create the need for services that a I to this child h^ e '°°"'s "s v r; r w_erp+h. cra'. 5 • S ,h ki4F uAc„ 4 �,a, '.rF r:, , 'SP ;',;::'�,^" t4, 5 Y y 3.Y aex tivr�. rrL+s�37,t'� ..rrr .. Yy •,� • t,ifrk:yy. 7 e r to .:.p. #,��:.... s v...... va r a,at�.. rat' .. r a .."i zjt� ,"315ja ,f.,-,,,,:i4,.:1,‘4,7:1; a #M h i Ls4-29.. E �t. d 2 ^t . 81 t " ' n r 1,t;�i si r ,a s ,k ga a .' '* ,a..--;,:,. a'L: !"4& s.:ft Litre � a "re a ,1, . a£,a;, k 'aP4 , ii` g„ . 'i a � _ tz�e a:#..al p4�..mad"�ue Fx,.dt+�xdxv �t �3F ,: .. ... . ... .,,.,. .< Inappropriate Sexual Behavior ❑ ❑ 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 ❑ El ❑ 0 0 Medical Needs ❑ 0 0 0 0 0 0 (If condition is rated"severe', please complete the Medically fragile NBC) Emancipation ❑ 0 0 CI 0 0 Eating Problems ❑ 0 0 0 0 ❑ 0 Boundary Issues ❑ 0 0 ❑ ❑ 0 0 Requires Night Care ❑ ❑ 0 ❑ 0 0 0 Education ❑ ❑ ❑ ❑ ❑ 0 0 Involvement with Child's Family 0 CI 0 0 0 CI 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 FsqeXtIffi_ attAWX+/+P.e+vVxxLt.otttct4t,.+2c,-+f:.lntrty,s::‘i. 7-my we f xa 144;4178 ,:r- i1kd 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 #14 +$.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) Li $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) tiO $36.16 3 1/2 +$.66 Respite Care gra Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) T$® Assessment/Emergency ttx Rate =. ; $30.25 day/$920 month(Includes Respite) (30 day max) kF 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 t. �:oard WELD COUNTY BOARD OF SOCIAL S de SERVICES, ON BEHALF OF THE WELD � �` COUNTY DEPARTMENT OF HUMAN SERVICES By: � � ., ': �i►,f_.�►?.,r By m Deputy ' lerk to th WS C air Si nature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Ramos, Julian OF HUMAN SERVICES 2029 17th St Greeley, CO 80631 By: i ector By: aC/( 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 111/0AU" -2 1. THIS CONTRACT AND AGREEMENT, made this date, / (90/0 by and betweeh 11=2!4 the Board of Weld County Commissioners, sitting as the B rd Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Rasmussen, Dennis and Diane, Provider ID#104555, 345 Gypsum Lane,Johnstown, CO 80534, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 t9C/C - o?/ll 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-I11/99) 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 t WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: %��y//!� ►�'r.rs:'''_ �� ti.�, 31 ltir�l Deput erk'to th r; $ hair Si nature Jte 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Rasmussen, Dennis and Diane OF HUMAN SERVICES 345 Gypsum Lane Johnstown, CO 80534 By: By o�ti G irector /({�1��J��y 4 . BY: /J /Y7 A . �Vyrn it 44-# .e-'L .) 3 &C/o- .2/u' WELD COUNTY ADDENDUM /!e To that certain Individual Provider Contract for Purpose of osteI"CR2e / st II: 24 Services and Foster Care Facility Agreement(the "Agreement") between Rasmussen, Dennis and Diane and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this } day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms o h 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#104555. 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 ❑1)One round trip a week ❑1'/:)2 round trips a week O2)3-4 round trips a week. ❑2%)5 round trips a week O3)6 round trips a week O3%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? 0 Basic Maint.)No participation required DI)Once a month 01%)Two times month O2)Three times a month O2%)Once a week O3)Two times a week O3'A)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%)%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 DI)Less than 5 hours per week 01%)5 to 7 hours per week O2) 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 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.) 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. O2) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑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/intensity of conditions which create the need for services that a..1 to this child. i n Z "`� � 'i5 .4t21 z d �n.v{ LaJsia E �i tea D, "A i�.x' a '° tx. k • i 1-t • ryt , k i 1 ,. * Eta i +a.l'a *--;'.,•;r.:ti 'e$'t.X , 1,' x. ' a a.w .. +.1�,a : :v""_s '. ' . ..:zs"'.�,*`ic.s,- .. x`4rr•*,-..5 "'wi :._ .... • -, �y5. ,.n#.,'..°�'i:t : .: ., '': '""u� � sa'�ti � t ;y�:d:,ts c!a� trt �. a .F x ..>r......< . . ,,.m'?: w . _...:.;.f.',2;1,4:14.kW:, Aggression/Cruelty to Animals ❑ ❑ 0 ❑ 0 0 0 Verbal or Physical Threatening ❑ ❑ 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ 0 0 0 0 ❑ 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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••I to this child. 5 s 3fi� 2 ri .,. '?� �. i ' �, s` n x ; 3 z a � 1, r& )., :. i , 't'*,.. . `- r s x `,' dam fa?'•q'# ate ` }? rr 'a e, a ''a `'I"a � s p'` t"f tli.4Syl. g.: t.°` 9t'R s ' m,it` gym eta •.f "' tz.era I dh:. t ,,, O ar i § , Jh c a v. ,� xn.?ara' a s t a av ; r ro .�,..,." W w P . . t e. , a $ i.....d:;.,'.. .. ew°;aw y La . . �....... -',. . r.,1 ,....,,:. `„a Inappropriate Sexual Behavior ❑ ❑ 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 ❑ 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ ❑ 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ o ❑ ❑ Medical Needs (If condition is rated"severe', ❑ ❑ 0 ❑ ❑ 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 0 ❑ Eating Problems ❑ ❑ ❑ 0 0 ❑ 0 Boundary Issues ❑ ❑ ❑ ❑ 0 0 0 Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ 0 ❑ ❑ 0 ❑ ❑ 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-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE �3SS;S a.o- A loaf � �a aazx.�T 4t +N p Ft�urc%�`v'}'ir'� }' • 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 1 141 +$.66 Respite Care ;�. Total Rate= ($20.39 day/$620 month) $23.01 1 112 Art +$.66 Respite Care 4,4 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 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 dayl$1220 month) PAO Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) Effective 7/1/2008 S Weld County Addendum to the CWS-7/ • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By. lei' Ali:.�,� _ �,� By: Deputy " lerk to th��` �*: � � Chair gnature ��►r SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Rasmussen, Dennis and Diane OF HUMAN SERVICES 345 Gypsum Lane Johnstown, CO 80534 By: BYSI, ( • ector de-7c)- c2l N 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-IU/9V) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1 1. THIS CONTRACT AND AGREEMENT, made this date, J �2(yb by and between the Board of Weld County Commissioners, sitting as the B d Social 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, 2010 and continue in force until June 30, 2011 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)2()/( --(72) CWJ-/A (KIU-IU/99) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 (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 CI-rk t,�\ =ilarL % WELD COUNTY BOARD SERVICES, ON BEHALF OF OF SOOE WELD CIAL • COUNTY DEPARTMENT OF HUMAN ,a•q SERVICES By: A , �- i. 1d/i� I!i �:j .. B .Iial ic,cJ Deput ler to the Chair ignatur •. saEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Redding, Christopher and Sonja OF HUMAN SERVICES 2305 42nd Ave Greeley, CO 80634 By: By: /-1VA f 'rector 3 o?EOI ) - • / WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the"Agreement") between Redding, Christopher and Sonja and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this I day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of 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#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. ,?r/ /2194 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. 1 I. 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 ❑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 ❑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? 0 Basic Maint.)No educational requirements 01) Less than a'h hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 ''A) 1'/r2 hours per day 03)2'/z-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week 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 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 ❑2%x) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3/)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. 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? O 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 • (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.11 to this child. Tic,itVfl .g .. ^t'w "' ' r A : ttV 'v4YA' m-f Ph. Y .t ,,ti h �4 a ' ;r e ms* ". g. *%. "Rt � `�";;'¢¢�'' t� r ivi +: 1 f t _ �' �Y" F4e P bik^ X11 ` ,,i4 Aggression/Cruelty to Animals 0 ❑ 0 0 ❑ 0 0 Verbal or Physical Threatening 0 ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior O 0 0 0 0 0 0 Substance Abuse O 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DNS 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. { ,�.�?Bpi """A u-`§ a., �,, sF' 'W` 1,::?: q n+'r ~,: „ „b; ^ r".y ,&` .x71- .a cnz s Rh i s �. ? r4 >i� Y *:%t; . 4.Y c.','' �`a 44{. ,-:-.1,F.,K.: "' s a `nv'' . na y ., . a xf3.r , ,L...!".,€1,, ,1 : 5 I Inappropriate Sexual Behavior 0 CI 0 0 0 0 Disruptive Behavior ❑ 0 ❑ 0 0 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ 0 ❑ 0 Depressive-like Behavior ❑ 0 0 ❑ ❑ 0 ❑ Medical Needs CI I: ❑ El ❑ El ❑ (If condition is rated"severe, please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 ❑ 0 0 Eating Problems ❑ ❑ 0 0 0 0 ❑ Boundary Issues ❑ 0 ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ 0 ❑ ❑ 0 0 Education ❑ ❑ ❑ 0 ❑ ❑ ❑ Involvement with Child's Family CI CI CI ❑ CI CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 [In ❑ 1'/z ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE u �• Ude 314#fit A•e 0-10...$16.32/da $496/month County Basic X.q. Aqe 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) Mgri $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) 11,0 $23.01 1 1/2trws. +$.66 Respite Care Total Rate=($23.67 day/$720 month) mas $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 i."11:11! +$.66 Respite Care au 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) (30 day max) 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 p;.v WELD COUNTY BOARD OF SOCIAL Edda SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN ' .I.T. ��; SERVICES or • By: Deputyrlerk to the �ti �Iw#..._ C air Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Redding, Christopher and Sonja OF HUMAN SERVICES 2305 42nd Ave Greeley, CO 80634 By: By: I� ector By: (3?67(7— /9 9 Weld County Addendum to the CWS-7A 1.WJ-/A(KIU-10/99) • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, /tom, I Q by and between the Board of Weld County Commissioners, sitting as the Bo d of oaial 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, 2010 and continue in force until June 30, 2011 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/ t9/ (-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 LWS-/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 C -r a WELD COUNTY BOARD OF SOCIAL y '!� SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN ` 116 It'd' = SERVICES By: we'AtzAtzi iv Deputy lerk o the a Chair nature Approval as to Substance: PROVIDER SEP 2 0 2010 WELD COUNTY DEPARTMENT Reussow, Robert and Tracy OF HUMAN SERVICES 4124 W 8th Street Greeley CO 80634 By: By: irector I 1 By: Qgt &`•2/7 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care fiwipt Asregne "Agreement") between Re w,s o o ert and Tracy and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this 1 day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms o h 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#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. o?12i1- 62/16, t 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 ❑l)One round trip a week ❑1'/:)2 round trips a week 02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week 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 02%)Once a week 03)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a%hour per day ❑1'/) '/:hour a day 02) I hour a day 02 %) 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 Do 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 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.) ❑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. ❑2%n) 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? 00)Not needed or provided by another source(i.e. Medicaid) ❑I)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 DNS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behaviortensity of conditions which create the need for services that a I to this child. d177-7.t—°"-- °kt �eraM1 h4 Sq ,,.. m S:1 a, lry 4 ti t t ^� .was..w�afi:..'� 'ee:t,-..x:u,i��'�+C .. b. ._•.. ".. _ ._ .. . ...._ a ate,>.. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ 0 0 ❑ Verbal or Physical Threatening O O 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 O O O O O Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..l to this child. ":itk " $ yc y a mR k ' a x 4�'t' 'fin :::: ; i t„... ',3 .:'hA 4�h'�i '? %4 Aa:6.'v!S "'v'Y 5...,_ 4 :5 , s n°�r �� ; ar -1.1,0A � s .�a q.:-.4.1 e�'kg $ +a:��..p�.¢; €it, Pk rs,�ya} b '�a do-.P`.c •i'°;4:� ..• , .,. .: .. .'� .a . .�`' . 4aR.% Inappropriate Sexual Behavior ❑ 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", 0 ❑ 0 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 0 0 Eating Problems ❑ ❑ ❑ 0 0 0 0 Boundary Issues ❑ ❑ ❑ 0 0 0 0 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 ❑i ❑ 11/2 ❑ 2 ❑ 2'h ❑ 3 ❑ 31/4 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE : tC 4 . tpit SI 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) tia rasri $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) al $26.30 2 +$.66 Respite Care tf 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) kis $36.16 31/2 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) pc 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) ria Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) Effective 7/1/2008 8 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to t -.�. d WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD �' ' � COUNTY DEPARTMENT OF HUMAN ,� , � SERVICES H 1161 '1�2 '? By' �aI!// / L� .t %t.�:✓' B s.tact,LJ Deputy lerk to the :�it� r IS Old Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Reussow, Robert and Tracy OF HUMAN SERVICES 4124 W 8th Street Greeley CO 80634 B . I l� By: l hector B ' 412 9 Weld County Addendum to the CWS-7A q LWS-/A (KIU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 4/nvt/ V jth 4+'1. THIS CONTRACT AND AGREEMENT, made this date, I �0/d by and betweenthe Board of Weld County Commissioners, sitting as the Bod Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Ripka, Gary and Jennifer, Provider ID#1538429, 2113 74th Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 r� o2C/7" a� I,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 CWJ-/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 WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD z-fir f �V . , �` COUNTY DEPARTMENT OF HUMAN ` SERVICES By' i n / iI!•�!. ,/ y,�.? � � By. s l/ Dep Clerk to Chair gnature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Ripka, Gary and Jennifer OF HUMAN SERVICES 2113 74th Ave Greeley, CO 80634 By: a B : • "��` titila-ector vv By: 3 4r/11-02/94 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Ripka, Gary and Jennifer and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this t day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms o th greement remain unchanged. GENERAL PROVISIONS County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1538429. 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)CC' -o? i 9� Weld County Addendum to the CWS-7A C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System(FIDOS). 6. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 8. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 9. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 2 Weld County Addendum to the CWS-7A PROVIDER SHALL: 1. Attend or participate, if requested by the Department, in staffing a child's placement with the Service Utilization Unit. Provider shall be notified by County staff of the date and time of the review. 2. Request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. Cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 4. Have medical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. Attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. Immediately report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. 7. Maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. Maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. Maintain/update medication logs on a daily basis, if child is taking medications. 11. Maintain behavior observation notes as required by the level of care assessed for each child. 12. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3 Weld County Addendum to the CWS-7A C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local)terminated for cause or default. 13. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 4 Weld County Addendum to the CWS-7A (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? 0Basic 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 ❑1)Once a month ❑1%z)Two times month 02)Three times a month 02%)Once a week 03)Two times a week ❑3'/z)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements DI) Less than a'/z hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 '/s) 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 ❑1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2'/z) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑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 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%z)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 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. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A S-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..I to this child. I s tai relil P � tlt F t 7:'4;5,+" eilt7ri*V°ti irre y d. P: S x-a..!te u n D. t s 11:5;;;;;;;;I;;;;;255; r "k' r°:5 r Via' ,' 55;"o S3�.'55454555:l5.255;55.;:.;.;55.55.: 55154 50,5 �553 5 is '355 } .,,.fit ; k;: *ka i..F. 'u.k..'i �_ re"t "n rS, s ("t2 a *{ v4s . ey t c a a re w a+r, rte.. . _ .-:&,:. ... . „.,...,..,..:...z. P's+.m 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 Enuresis/Encopresis ❑ ❑ 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A • - (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child. 4x '1v ' „ x °.� ., t v .sfits 111.6�+# ° a Fyn : .ya=4 x Id 1" s I .f..4.;ev A,Ai:`"� ri `t` '1:5.w3 x s >. #Iza s e '" '", 4 :a„w' S , ,}w M il .;5'3 x v ,tv°,±y„ is s a: a # '#e& ° l',1-:4,k s t " t. yax r k q, 4 • .. rt'§. .0 "v:s g.' rr4 a iq t#'.,s0' at ' ilp; s `r 'yn s x rs,. 'sa"*1iw; , ys E $e Via" d rioir�' t #4bz .... `. g , % if f e - ;i fi e;.0 . l;: 65,3 a � did!..¢ . 4 '" �' �.wl.t.�'xq#ti...*.`"u. a"k�sx'4;S.::..�... »s. . . .. .„ evi.;: �. .. ... , ,. _, .s�≤�^ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ 0 ❑ ❑ 0 0 please complete the Medically fragile NBC) Emancipation ❑ 0 0 ❑ 0 0 0 Eating Problems 0 0 0 ❑ 0 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ 0 0 0 0 Education O 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: (cheek level of need) ❑ 0 ❑1 ❑ 1'/ ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'A 7 Weld County Addendum to the CWS-7A S-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE •47, gat psi Ate 0-10...$16.32/da $496/month County Basic At 11-14...$18.05/da $549/month Maintenance si Rate Ate 15-21...$19.27/da $586/month +Respite Care$.66/da $20/month) $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care 0.9 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) VEN $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 +$.66 Respite Care TRCCF Drop Down Total Rate=($40.11 day/$1220 month) Assessment/Emergency 411 Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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- B.ard WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES d.t '.1 2 Ism By: ❑.�Q •, By. 0.I Deputy ' lerk to the :'�t�: 1 0 Chair S' nature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Ripka, Gary and Jennifer OF HUMAN SERVICES 2113 74th Ave Greeley, CO 80634 r� d By: U B .. 'rector 9 Weld County Addendum to the CWS-7A I:WS-/A(KIU-IU/99) r INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 2019 A NI II:2-7 1. THIS CONTRACT AND AGREEMENT, made this date, TV 2j 0 l t 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, Risner, Larry and Vivanco, Katherine, Provider ID#1552270, 1104 N 3rd St,Johnstown, CO 80534, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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. 1 020/0— (12i � I;WJ-/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) 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 i�`' �% WELD COUNTY BOARD OF SOCIAL ®� SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN iikt5' SERVICES Depute lerktothe4`'/"IQ.�� Chair Si nature � SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Risner, Larry and Vivanco, Katherine OF HUMAN SERVICES 1104 N 3rd St Johnstown, CO 80534 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 Risner, Larry and Vivanco, Katherine and the Weld County Department of Human Services for the period from July 1,2010 through June 30,2011. The following provisions, made this day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of the greement remain unchanged. GENERAL PROVISIONS County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1552270. 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. QcJC- c9!is 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 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 sLa` SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN R :Igl�i SERVICES 1.61 ikt2 i w.r By.. tom//l/ i ��lL�- /"J- 1.?! .-. J By: Deput " lerk to the�' ��( r � � Chair S gnature ��►�� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Risner, Larry and Vivanco, Katherine OF HUMAN SERVICES 1104 N 3rd St Johnstown, CO 80534 By: By: D rector By: o?c/e)- /cie 9 Weld County Addendum to the CWS-7A LWS-/A (KIU-IU/99) 4. INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 2010 Auc 2 1. THIS CONTRACT AND AGREEMENT, made this date, c20/6 by and between_ ?S the Board of Weld County Commissioners, sitting as the Bo d So%ial 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, 2010 and continue in force until June 30, 2011 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 acre (9)9 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 ew3-/HcAll -Iu/ 9) 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk tot 1? aft" L % WELD COUNTY BOARD OF SOCIAL v SERVICES, ON BEHALF OF THE WELD i Mr _ - COUNTY DEPARTMENT OF HUMAN i tritficgril SERVICES By li & Is-VI B YNn6P � p le k to the Bo- `Nt- ( Chair Si nature �.."� SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Ritter, Thomas and Deborah OF HUMAN SERVICES 10151 Devonshire St Firestone, CO 80504 By: By: irector By: 3 ??C/C- 02/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster�C �2a a Services and Foster Care Facility Agreement(the"Agreement") between AN�f'n Ritter,Thomas and Deborah and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this 1 day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of he 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#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 will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. -,9/ 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 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 ❑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 01%)Two times month ❑2)Three times a month ❑2'G)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 01)Less than a ''/3 hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 %) 1'/r2 hours per day ❑3)21/2-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed DI)Less than 5 hours per week ❑1'/s)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 ❑1'A)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 I. How often is CPA/County case management required?(Does not include therapy) ['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑l) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 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) DI)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/mtenstt of conditions which create the need for services that al.1 to this child. _i x- a,y R^x':{�: ':#s kwx '� /,.v y... r x • � *.tr71r - W`mw a' "i x. '1IE' r.' 'e hfir °:` '1#°x°,`*'^ ,` > s. 4 .0 .2(4-44/1- V. 's z.,n°3..'n r#xa d ti � cggec s : r an!`,+4• C. a.:.fw i 4�1 , Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ 0 Verbal or Physical Threatening 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 0 Enuresis/Encopresis ❑ 0 ❑ 0 0 0 0 Runaway O 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behaviocintensi of conditions which create the need for services that a..1 to this child. a'3 ` ' ''Please r xr or/i„, c t5ieTt , 'r'S st . w" �x'� :a 4 rtsH *. r 'L 3 d d �. F A ? �w''' yA $ I "�p,L�bT '';':-'''S.7'. Y d y't°jl irr;Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ 0 0 0 ❑ 0 Delinquent Behavior ❑ ❑ ❑ 0 0 0 0 Depressive-like Behavior ❑ ❑ 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 Eating Problems ❑ ❑ ❑ ❑ ❑ 0 0 Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑l ❑ 1'/z ❑ 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 RATE TABLE • s� a r• A.e 0-10...$16.32/da $496/month County Basic A.e 11-14...$18.05/da $549/month Maintenance tril Rate A.e 15-21...$1927/da $586/month +Respite Care$.66/da ($20/month gra $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 ata Total Rate=($26.96 day/$820 month) $29.59 2 1/2 4.66 Respite Care fis 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 111 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 Rate $30.25 day/$920 month(Includes Respite) (30 day max) Effective 7/1/2008 8 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the B..rd WELD COUNTY BOARD OF SOCIAL 5 SERVICES, ON BEHALF OF THE WELD rJ `-"`�`� OUNTY DEPARTMENT OF HUMAN : RVICES 1 NI - By i��/L�/ i ��%� �/��:61 .,4y Depu Clerk to the Boa:q U14-\\ Chair S gnature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Ritter, Thomas and Deborah OF HUMAN SERVICES 10151 Devonshire St Firestone, CO 80504 By: By: Di r ctor 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, I JO) l) by and between the Board of Weld County Commissioners, sitting as the B rd S6cial Services, on behalf of 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, 2010 and continue in force until June 30, 2011 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. N 6. To keep confidential the information shared about the child and his/her family. U 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 th4,ild at any reasonable time. 1 CWS-/A(KIV-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 S-/A IKIU-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. 40.ATTEST: Weld County Clerk to t1/4.11-:0-- ` £uea% WELD COUNTY BOARD OF SOCIAL `' 0. '% COUNTY DEPARTMENT OF HUMAN OF THE WELD • V t.at,1 SERVICES By:/l .k / �, AA/4)X?t /` By: 0 'S „/..t Deputyrlerk to the Boar. �= h it S gn ture SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Roderick, Douglas and Kelli OF HUMAN SERVICES 3110 57th Ave Greeley CO 80634 By: By: U_ irector By: 3 o?CW) --,72 JY • 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 1,2010 through June 30, 2011. The following provisions, made this l day of 2010, are added to the referenced Agreement. Except as modified hereby, all terms 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#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. ^a 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 theUght to deny payment. ff B. Be submitted by the 4th of each month following the month of service. Ithe 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 th `�rovider 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 amain of work or deliverables lost to Human Services; E co 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 ter each child. ^' CO 12. Assure and certify that it and its principals: -D A. Are not presently debarred, suspended, proposed for debarment, and ddc'1ared 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) N [ ) N a7 U J= Ul 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 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? 0Basic Maint.)Less than one round trip a week 01)One round trip a week ❑1'/)2 round trips a week 02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week ❑3''/)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑l)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 '/x hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 'A) 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 01) Less than 5 hours per week ❑1'/)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 011/2)5 to 7 hours er 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: to A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.)Face-to-face contact one timeper month with child and no crisis intervention. (i.e. mutual care placements.) rs DI)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/:) Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) DI)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS• NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate ,ythe behaviorhntensit of conditions which create the need for services that a.'I to this child. 3 .•�t - ra s'; - 111,5 '��a .3t ?t,, x a z ''' Nctig!f'' ' ; : •. c1.: e4 s4 -' rJ . " 't' "t.y. r t,,�'ry-v. • ::111.:,,l,...1 x y.; S .:.A.' : 43 x„... 1, %'e #.vT"_i,..M ''. ` is:. - :..e 5t itrw..u.;f .....:: .. ,.,:.. . . e,,e ...v..er ,,!.. Aggression/Cruelty to Animals CI ❑ ❑ ❑ ❑ CI Verbal or Physical Threatening 0 0 0 O ❑ O O Destructive of Property/Fire Setting 0 0 El 0 O O O Stealing ❑ ❑ CI ❑ ❑ ❑ Self-injurious Behavior CI 0 0 0 0 0 0 Substance Abuse ❑ 0 0 ❑ 0 0 0 Presence of Psychiatric Symptoms/Conditions CI CI CICI ❑ CI ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ 0 ❑ ❑ 0 v Sexual Offenses v ❑ ❑ ❑ ❑ ❑ ❑ ❑ Ni Co 13 if cm 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..ly to this child. 3'dt " y"a' ₹ wB�i. 1 `4'a "4 §t..v erxRT:44"44 s rP y, p : :../;.... /T.':,./,..-2/„ a.n �x g: ^Ztiti kr,7,lml ac, 'iitit, x"t' r FIFA *i§ f 7,1 ta,� S S a`a a F y'r Sys 9,FI I` ''a' 1 4'c ", !,,s?,',-:44.1i, '•i4 p t" 444. �'.. 9ra,�, .yfr" 3 i ,+...:.?1:4.O.,-.;,'Li,'.:,v if,, e a"n Ii,& a i4,1 ,. ' 's. t y t y e Elie '5 4 to` t- '$ `4 �: ,.,� s++��+.'yy '� h'�� f t i iii!.:,;:}1. :, r v. "� Inappropriate Sexual Behavior 0 ❑ ❑ 0 0 0 0 Disruptive Behavior ❑ ❑ 0 0 0 0 ❑ Delinquent Behavior ❑ ❑ 0 ❑ 0 0 ❑ Depressive-like Behavior ❑ ❑ 0 0 ❑ ❑ 0 Medical Needs (If condition is rated"severe", ❑ ❑ 0 0 ❑ 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 ❑ ❑ Eating Problems ❑ 0 0 0 0 ❑ ❑ Boundary Issues ❑ 0 ❑ 0 0 0 0 N G Requires Night Care _ ❑ ❑ ❑ ❑ ❑ ❑ No ❑ tb Education 1J ❑ ❑ ❑ ❑ ❑ 0 ❑ cr Involvement with Child's Family 0 ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'A ❑ 3 ❑ 3'/z 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE _''. ,. . . `x YF '"galctp s .k °ia3:S'h '453 ritgz A.e 0-10...$16.32/da $496/month County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate PPAge 15-21...$19.27/day ($586/month) PP +Respite Care$.66/day ($20/month) $19.73 1 c61 +$.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) 1)14 $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) lip $29.59 2 112 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care Ni Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month)PP ry co erP Assessment/Emergency Rate0;1 $30.25 day/$920 month(Includes Respite) c7 (30 day max) =piD Effective 7/1/2008 Ul 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 A 4% SERVICES By Deput Plerk to th��:T: � ' � � Chair 'gnature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Roderick, Douglas and Kelli OF HUMAN SERVICES 3110 57th Ave Greeley CO 80634 By: By: . .1 � ILr D ector By: ti co D r cn 9 Weld County Addendum to the CWS-7A S-7A LWS-/A (K IU-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT ,n't jui_ 26 PM 3: 44 1. THIS CONTRACT AND AGREEMENT, made this date, R/Z/ /2010 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, 2010 and continue in force until June 30, 2011 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 , 9G// - ate/ � L W S-/A (KIU-1U/99) U-1 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 (_,WS-/A(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 th- f.'� �� WELD COUNTY BOARD OF SOCIAL 11:a SERVICES, ON BEHALF OF THE WELD A}; COUNTY DEPARTMENT OF HUMAN SERVICES t9.6' 11.'441A$Z- *1 By. �n Deput ' lerk to the Bo?+y�ti Vitt' II Chair ig ature. wi sEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Rogers, Jeffrey and Tami OF HUMAN SERVICES 5221 Bowersox Parkway Firestone, CO 80504 By: Qror49 13 By: U 3 cW)C -- a/96 • 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, 2010 through June 30,2011. The following provisions, made this 21 day of J I y , 2010, 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#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. 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 01)One round trip a week ❑1%:)2 round trips a week 02)3-4 round trips a week. ❑2'/:)5 round trips a week 03)6 round trips a week ❑3'/:) 7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required DI)Once a month DI'A)Two times month 02)Three times a month ❑2'A)Once a week ❑3)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a ''h hour per day ❑I'/) '/:hour a day ❑2) 1 hour a day ❑2 ''A) 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? 0 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''/) II to 14 hours per week ❑3)Constant basis during awake hours ❑3'/)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond 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 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 ❑3/)21 or more hours per week Comments: A 1. How often is CPA/County case management required? (Does not include therapy) 0Basic 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. ❑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) ❑I) 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 OHS NEEDS BASED CARE BEHAVIOR ASSESSMENT tp Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. ;,$';1 794�, it n S + .r`.'y : -t`,°ry yr: ufci k y'ty ,. ;�' ',;:;1'-': • s .0.7,.; 40:5:212%;" _ a ,2/'` , : . t d3s'y' +, yt4 s: n&mTs�,,`tt.'�.'. • yid ; to s " ' k s . '" :+`t` ',".^.9.1".;.' ". ,4 t i`F v''' ,,{a. '� �#''§. re : *"'xt ynk #:cr," y�h - ₹ ,'Rc. � °, a -. S ray it. a S ,4 ty-� knit r ':.r � 'tile ' tf * t,y '�" Kr L i d2+4 4. . s . ' 7..", L r ro� a x �� r x s ?1.%:".3'....,} "I .34 i 3°ltd^ h, : <, y' a W'� s +. d.I..ttx �.• '`. Aggression/Cruelty to Animals 0 ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 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..I to this child. ,S, mom.; ui�la�,,uu j .�$$V�..�� '� i. Ynay,q i r,'. }ry yA' h ¢ $e ¢ 3 .. 's* ,.+ ' +d }:y�b '�"$S '°+- td 4"6' a°v�f+ 4'^: .vu{; u } r 4"1. i `Y'�4 '` . "fi n e. i�� 'y t . 4�° :; *• � z. 4 § § A � ' C ,-- �+ t4H..: Y!'zT'.u...: : YY. . . m.4u h9 «^:7:;, M {,f--'A. f s ..: ,a � k t.y "n`&.2y�r�F� i° }$ i W;t2:'sYi;iin w'$ r 'h..'dr. 4._-hA�'+ s'i "ve'� 'i;' ) : Tt^'v� Y44s' °s ibs 54 v° 4�Smar _ ':ils gj1 kt t s 4 s y y y�� ani ^'ns ;.'H'Yx ' II," '�$} 7S *� xf K 'n^v t w"* rt s c i ¢ b «p,` '.. , ,1 Yr�t t,4 w ,�:i , ,ta: 1a •;!¢44.4 f k- m. Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior 0 0 0 0 0 0 0 Depressive-like Behavior ❑ ❑ 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 Eating Problems ❑ ❑ ❑ ❑ ❑ 0 0 Boundary Issues ❑ 0 0 0 0 ❑ 0 Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 ❑ 0 0 0 0 0 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-7/S-7/ (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE `'5a av' ij,t tl to a. , '?'s'v tt i ItifltflkJ! • Age 0-10...$16.32/day ($496/month) County Basic Me 11-14...$18.05/day ($549/month) Maintenance Dre ..::;.Rate A.e 15-21...$19.27/da $586/month +Respite Care$.66/day ($20/month) $19.73 +$.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 zogi 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) $36.16 31/2 +$.66 Respite Care 41 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) (30 day max) 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 COUNTY DEPARTMENT D F HUMAN .l►., SERVICES By: � By. Deputy r'lerk to the Bo s [Jr�S Cha r Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Rogers, Jeffrey and Tami OF HUMAN SERVICES 5221 Bowersox Parkway Firestone, CO 80504 By. By. l rector y: 7 /2// cY( /O-- 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-IU/`J9) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT ID /� 9 pM I: 30 1. THIS CONTRACT AND AGREEMENT, made this date, (7 y2 _ by and between the Board of Weld County Commissioners, sitting as the Bo rd of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department"and, Rothe, Terry and Marilyn, Provider ID#15169, 4115 W 20th St Rd, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 ç9 /(1 .,)/`/ I,WS-/A(KIU-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 LWJ-/A(KIU-IU/99) 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk tot WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN • ' ;��"% SERVICES leer r By. L.!.:Ln�. ` � BySe5 rrnv/ J Deput lerk to the Boa"t � / Ch it ignature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Rothe, Terry and Marilyn OF HUMAN SERVICES 4115 W 20th St Rd Greeley, CO 80634 By: By: rector By: Z 3 ii2 c2 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement(the "Agreement") between Rothe, Terry and Marilyn and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this JO day of wit , 2010, are added to the referenced Agreement. Except as modified hereby, all terms f the Agreement remain unchanged. GENERAL PROVISIONS I. 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#15169. 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 teens 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 01)One round trip a week 01%)2 round trips a week ❑2)3-4 round trips a week. ❑2''/)5 round trips a week ❑3)6 round trips a week ❑3%2)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 ❑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 01)Less than a '/2 hour per day 01%) 1/2 hour a day ❑2) 1 hour a day 02 %2) 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 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%2)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? DO)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-7j (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,......tea,"5 , ^d' y u a.,j ta; r +K �,+h„ ,a q yx.� ikt, u' �" " ar - .. ;1 p i� rttt Ft.. i A• ♦ ,- Y. h 4 £p 4: . t Y a gi7+� 9 ` SI:eu�- vct "�t as1V:11 "1, b' ..-.5:1:::.14;144:'' t "`,uS"'-^ �..1Y'{ ''':)1!'i#2' y ,l rc% tii R x?o'.s .1 t 4' .„a—°i .: . tY: > �ti ks ,,tdh'4r.`. 4 . t' "�- 5 ti:fi "�Fetr'4-t- it v k - s" f i..fir 'sm ',' ws`KK`�� t,"��.n. . s y . m}} aPt ;11,1,1- , T t,. , p P 4g t "b' Y . '1 � §....xw - a 4 } b s iliAl y w t .iii §.x'a ar 1 f� '� y.n ? S y � s rtiF�, '�;" , ay. �-t,.�'� 'a;G. .i . yAx e . . r P•. ' t-40-.4. 1 3 i': :ra"L ,ay—vt;aa R e- :+ ^� fit tai, ' ✓ v•y t;r a r� a-+ ki✓ } a • ° t4k R ₹ M1 t �r;9 '{rY9 ; 4... i ^ ge1Z YY ,,•!,..:,:, '..5 ,. '�"� :.:' 1 ' 'r"t.�'5 �'f4'�3,'hw�...7, :,'t'�N 8 . '�' .4 � �. � F ^oc� t.+? .. ;:... h== v� , _....,,. _ ."_._��"._..n`� Aggression/Cruelty to Animals ❑ ❑ ❑ 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 Self-injurious Behavior ❑ ❑ ❑ ❑ O O O Substance Abuse ❑ ❑ O O O O O Presence of Psychiatric Symptoms/Conditions O O ❑ ❑ ❑ O O • Enuresis/Encopresis ❑ ❑ O O O O O Runaway ❑ O O O ❑ O O • Sexual Offenses ❑ O O O O O O 6 Weld County Addendum to the CWS-7/ • (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. +yip, "'4"'^ �k' r k s . -v t++szs.^� "a� a,.r�t t"�. . '�. P 4 :v...:w s q t a,...'s r , _ t,ua.3w l '_ ;=..��a..3...r.ata,.,sce,:wR:;a.153m *.a.a��s z:=.e,. . . .. • ,n. u ,�.. ..x , _.. .n�s'tu: Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ 0 0 0 0 Medical Needs (If condition is rated"severe'. ❑ ❑ ❑ ❑ 0 ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 El 0 0 Eating Problems ❑ ❑ ❑ ❑ ❑ 0 0 Boundary Issues O 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 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 1/2 7 Weld County Addendum to the CWS-7/ (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE -- -i-, - :.,..; '1, x. :, '£h' m .r n a R ' T*,t �� F 3 t'Fd¢y y. Y 3T * 5�Ti u re E h d i :. ':{..: - P'3+. Age 0-10...$16.32/day ($496/month)'IliCounty Basic Age 11-14...$18.05/day ($549/month) Maintenance Hi Rate ttii Age 15-21...$19.27/day ($586/month) Der tRit +Respite Care$.66/day ($20/month) PA c. $19.73 1 +$.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) Ll to $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$.66 Respite Care ilit Total Rate=($30.25 day/$920 month) ttE $32.88 3 +$.66 Respite Care 7140 Total Rate=($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care Total Rate=($36.82 day/$1.120 month) il 4 $39.45 TRCCF Drop Down +$ Respite Care PP Total Rate=($4a11 day/$1220 month) al VIA Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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�i_, d WELD COUNTY BOARD OF SOCIAL Vida SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By. " ,� , ►J.•:!�lr..�,'� � ``♦ a? �i; ( �� "[�� h it Signature Deputy ' lerk to the : : r,"/' SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Rothe, Terry and Marilyn OF HUMAN SERVICES 4115 W 20th St Rd Greeley, CO 80634 BY: By: 'rector By: 13L-&-v-L7 J`t5-nei ,2C/n-, J9 ' 9 Weld County Addendum to the CWS-7A UN/S-/A(KIU-10/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, I, O2O/O by and between the Board of Weld County Commissioners, sitting as the Bacad 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, 2010 and continue in force until June 30, 2011 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. ry 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. r 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 se@he child at any reasonable time. 1 ,a?9//?- 071% G W S-/A (KIU-W/99) U-W/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 andJo share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting rrclical needs, handling special psychological needs, and separation/loss issues. ti 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. r 2 UWS-/A (KIU-JU/99) 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. ' Togive 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 t..rt w�`` WELD COUNTY BOARD OF SOCIAL J5 SERVICES, ON BEHALF OF THE WELD / �j • A �, COUNTY DEPARTMENT OF HUMAN SERVICES By: � � � � ►� �:!?,.�s� ,ail Bey: � mss,-.�xr/ Deput P lerk'to the B0' '.% (` T� hair Signature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Rush, Phillip and Shannon OF HUMAN SERVICES 2540 S Flanders Ct. Aurora, CO 80013 BY: By: Director 3 99/(7-.„91W c ' WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care �z Services and Foster Care Facility Agreement (the "Agreement") between ' ' Rush, Phillip and Shannon and the Weld County Department of Human Services 'J for the period from July 1, 2010 through June 30, 2011. The following provisions, made this [ day of 2010, are added to the referenced Agreement. Except as modified hereby, all terms o he 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#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 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. Q(/C)-0q/% 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 (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P I. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? OBasic Maint.) Less than one round trip a week ❑1)One round trip a week ❑1'/z)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 ❑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 O2%)Once a week O3)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a ''/z hour per day 01%) %hour a day ❑2) I hour a day O2 %) 1'h-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 ❑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 ❑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'/z)5 to 7 hours per week O2) 8 to 10 hours per week O2'/z) I I 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.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. O2)Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑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 • (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. tit;-i );: ,.M`; @%,/ s d"}_xs r-si,46 g�trr( gye--... x ,-, =t " ,, ,rt..: ssk ` r 59`L.k ":i}� j.a +" t ', yp + '::::1,;,,, a Y t �e s a..h y t t r,' + `i ' .. ".y 'rii '` '' tx..t 1(u 7 sr«N.{'.;'in 5 ,w'.fi,y d _k 4; µ u e$" by ' k s "il i,' i �k^ f .''i., ' . ' a _. "` s+ >• >"-' ,�}.' r.�`i 4 *t- h7. . ,„, 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 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 ❑ 0 0 0 0 • Runaway ❑ ❑ 0 ❑ 0 0 0 Sexual Offenses ❑ ❑ ❑ 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/mtenst of co+�ndmons which create thi.-14€,-., eyneed for services that a..l to this child 4'�'`'� $ s, "nwiwi ,rvl" ,%c fix' l- art"t G, -.. •. sx t . ..:4",:,:::::::.y.:;4727::, N �' r�'` t§C " "lU i r . 3ry k .'j= rf �idt° r i4,t i' ' ce r r L 4. S.,•,-;:4,,7 � d t t st p x " r t „ . ..:::,;:ti�#� max t y ��a •'t � r 4zr � .�d' "fp^'rtt :,,,7,.,:v y °�' Yr t v rtr&i'4 . d°'. r a ....x. '..gw..aa......3 ns..r��`t....,.:S ,.0 ...k�I,A. .::.9 .� ,r rys k+ .� Inappropriate Sexual Behavior ❑ 0 0 0 0 0 0 Disruptive Behavior O 0 0 0 0 0 0 Delinquent Behavior O 0 0 0 0 0 0 Depressive-like Behavior O 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ 0 ❑ 0 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 0 0 0 0 0 Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1''/ El2 ❑ 2%z El 3 ID 31/2 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES • NEEDS BASED CARE RATE TABLE ' :� �. gy a5 Yye ✓ r rk'��'�y Age 0-10...$16.32/day ($496/month) County Basic "414,4ii A.e 11-14...$18.05/da $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) $23.01 1 1/2 R4ip. +$.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) it41:04;14 $32.88 3 +$.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) (30 day max) Effective 7/1/2008 8 Weld County Addendum to the CWS= IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the I3oard WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD • COUNTY DEPARTMENT OF HUMAN SERVICES lest By' i//!/. i.A��i�.�I_'•.._�'"� -� � By.11 Depu!Clerk to the (1 U 1 ai Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Rush, Phillip and Shannon OF HUMAN SERVICES 2540 S Flanders Ct. Aurora, CO 80013 By: By: _L t/A irector By: o?C-0- ai9/ 9 Weld County Addendum to the CWS-7A LWS-/A(KIU-IU/YY) 4 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, '7//5/ /U 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, Sands, Corey and Amy, Provider ID#1555552, 2026 27th Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. I /C-02 I�� 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 1i , I,WS-/A(KIU-IU/99) 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ® ATTEST: Weld County Clerk to t�! f. � WELD COUNTY BOARD OF SOCIAL % ERVICES, ON BEHALF OF THE WELD • OUNTY DEPARTMENT OF HUMAN �i.ERVICES By: L( .�i �_i !!_� Vii:_=:_' �'�I� By: zt r Deput F lerk to the Board Chair Si ature Approval as to Substance: PROVIDER SEP 2 0 2010 WELD COUNTY DEPARTMENT Sands, Corey and Amy OF HUMAN SERVICES 2026 27th Ave Greeley, CO 634 By: By: Direr B ) 3 ae)7c)-a/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility AgreemectOtIgripitreateinfhetween Sands, Corey and Amy and the Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. ��The following provisions, made this day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of th 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#1555552. 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 7 the month following service, it may result in forfeiture of payment. °WWI- ai,�� 1 Weld County Addendum to the C . A 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, filings in bankruptcy, reorganizations and/or foreclosure. 46 2 Weld County Addendum tot WS-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 C - A 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 ih C -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 01)One round trip a week /:)2 round trips a week 02)3-4 round trips a week. ❑2'/i)5 round trips a week 03)6 round trips a week ❑3%)7 round trips or more Comments: �L¢I waked-�Q� &an1 racy tot H / C .E .S vzse.O GLl tad .i0O4 PlAir P 2. How ofteiVis the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑l).Once a month ❑1'/x)Two times month 02)Three times a month Ml'/z)Once a week 03)Two times a week ❑3%)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a''/a hour per day /:) '/:hour a day 0211 hour a day 02 '/) 1'%-2 hours per day 03)21/2-3 hours per day ❑3''A) 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 r 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? +'Bhi�asic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1/)5 to 7 hours per week 02)8 to 10 hours per week ❑2'/z) 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.) DI) Face-to-face contact one time per month with child and minimal crisis intervention. ❑I'A)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%n)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? IDAYNot needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month Y75. I )4-8 hours per month ❑3)9-12 hours per month 5 Weld County A ndum to the CWS-7e (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. ', y# 3t *aai C° -t. .1:- - ..3 '•I i f'� j 7;i 4 6�gK rvY t i x 3 p t •"fi e q'" Wyk ., r fy. % ,4, 1 aµw: t'"R� x"17,11... x$"ca.T',....„,..",,A,�` ..,44 ' ..kev' '",-.rtr "ri d ' . t _ tt Vsi as {}^o- ° a{ kA. ?1,_1, +„ ..zialc Aggression/Cruelty to Animals ❑ 0 ❑ 0 0 0 Verbal or Physical Threatening ❑ 0 13/ El 0 0 0 Destructive of Property/Fire Setting ❑ 0 0 0 ❑ 0 Stealing ❑ ❑ 0 0 0 0 Self-injurious Behavior ❑ V ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 V 0 0 0 0 Enuresis/Encopresis / ID ❑ ❑ 0 0 0 0 Runaway „L--I!/ O 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 6 Weld County Add nd to the CWS-7/ (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. g'7f #x . :4,::::..:4, 1:4..,:: : ti * z ior/ t S �' t S'�AT" x . AR.., t ...i..,...: ..,. Cts vim, .t.c 'tl .r{ ` ,,,,7 : ;<az.7:'.pr" i a :- t,s afi» k f c„ ,.4).,„ 4T a. J� A.' y.:si` 4 't ��9, tit 4t - i f f t' WYl ,: d `"�IS0NCI'4 "P S ,,1n 4.,� 1 4 S S k41 .:'''J -.',,......1.--2,,,,:'ku�. ic: x , d ^d S i.+}. H. 4{i•ts" ity# ar ,` uw t , —.7:,. 7� r - �, `:A:,15* ' '' +g M�a.� ,caxf 'a ).A.;, aP. kp .,4,13-44.:...4...4.---,2.,,,,•:—.--g ..gr , - .. 4 't,,r.2 'y"°fa k ' fx r �: s„t "+` x� t 4t„,t u F s *�-. . t „ .tmT z_. t v 'v r, d ; fi ` t ' "§ it s a+�rr,,,i .. .. +akn`: 45v. ?3„f" t' . x>��.ti:.. 2 x. :d. d "� 5,' °.. Inappropriate Sexual Behavior O 1 I ❑ ❑ El ❑ Disruptive Behavior ❑ O O Q7 ❑ O O Delinquent Behavior / O O O CI CI Depressive-like Behavior ❑ ❑ ❑ ❑ O V ❑ Medical Needs / (If condition is rated"severe', ElC7 O ❑ El ❑ ❑ please complete the Medically NNN�� fragile NBC) Emancipation ❑ O O O O O O Eating Problems ❑ ❑ O O O O Boundary Issues / ❑ ❑ ❑ E ❑ ❑ ❑ Requires Night Care 7 ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ C7 ❑ El El Involvement with Child's Family O ❑ ❑ El ❑ 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 Add n m to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE '� �5y”�'1s�'nkMLY '5GSCk4Np'� ry tY' 3 x'31} a L r =LAO 6'..474eyettictd4e A.e 0-10...$16.32/da $496/month County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate A.e 15-21...$19.27/da $586/month +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care 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) k. Likig $36.16 3 1/2 +$.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) rit Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) Effective 7/1/2008 8 Weld County Add.m m to the CWS-7A I 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 I.. . WELD COUNTY BOARD OF SOCIAL ,Ie��\ SERVICES, ON BEHALF OF THE WELD N,COUNTY DEPARTMENT OF HUMAN " RVICES i —row By: / ' ActfL .Deputy lerk to the Bo.'',,*9 ( I N01 gnature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Sands, Corey and Amy OF HUMAN SERVICES 2026 27th Ave Greeley, C 0634 By: 'rector r/7 2i9% 9 Weld County Addendum CW -7A UWS-/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, AN() by and between the Board of Weld County Commissioners, sitting as the B rd 6{Social Services, on behalf of the Weld County Department of Human Services, hereinafter called"County Department" and, Schmidt, Donald and Constance, Provider ID81511343, 937 Clydesdale Lane,Windsor, CO 80550, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 CANS-/A (K 1U-10/99) 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:WJ-/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 t.4 ' 1. 4, ` WELD COUNTY BOARD OF SOCIAL • SERVICES, ON BEHALF OF THE WELD � tir. COUNTY DEPARTMENT OF HUMAN 3611 ' SERVICES • .."4:41F "a, By: • iii/d/. �' �!�:� D B ' .Arf✓/'� Depu Cl-S k to the Boar r+�' h Ir Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Schmidt, Donald and Constance OF HUMAN SERVICES 937 Clydesdale Lane Windsor, CO 8055 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 Schmidt, Donald and Constance and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this / day of 2010, are added to the referenced Agreement. Except as modified hereby, all terms f t 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#1511343. 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. ate- 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 • (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 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 ❑1%:)2 round trips a week 02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week 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 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 ❑I) Less than a%hour per day 011/4)1/4 hour a day ❑2) 1 hour a day ❑2 %z) l'/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 01)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 O 3%)21 or more hours per week Comments: A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) 01)Face-to-face contact one time per month with child and minimal crisis intervention. O 1%)Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A S-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..I to this child. + a a � �•7r�, r f..' I aka a"`-1tR --•3/4 lc,;- ` ' l ' c v. '3. ,j,, sry r'e xr S, `T y 5� a 7 p w � f a. ��411 a_ -* flag :. tr t _x'45 ��.GT+�`'`w�. �. m i 'a ke u�: v - '� �" 14:1,'-" •.aw•ian4ce y :° --41.44N4-%� -y'as•a K i \'.4,:`,.. '. *. a X '7%n* a 4 . .,, x h v ,y - 4y..' ¢car + ys a �:','"'.1:::i: ',§ e :, i, �.. - t; p °ut rsx,� 4 .. ... Si?)w 8 ,R: .at'?.. e d +�,,: a�5 '50,3,t?!erhtx.'k , , .. , e .,e,'re r �, � .-...,..03,,,z,.-..�' '' '. 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ 0 0 0 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ 0 6 Weld County Addendum to the CWS-7A (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. l'I'+�,� d. 1' 'a"". /rt; .` `"14 r `'4 a ":": *.7't+ a a J.:A ,r a "� § i y(' it'... „.1!#- I 9y1t kr?..:Vi�,.": "a.¢. 7' sa g i"01-..ii..",.. e. ti a� 'P a git 4 q arrl y�.a Mry ,,^,Is %- a y a { a kr'�k {y f a L. d o a.. ; .. v. f s n'� v k ,� . '. :' ' ._ ..:,'...3. hx .._.. �:: �ZIati. ° #—Tf ." d5a.;ti w"5 aa$d.a... .,..e".r. "c °.a. :A. 4w ".rk+'. fw w"Bw o- r Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ 0 0 0 0 Delinquent Behavior O 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 ❑ 0 0 0 ❑ 0 0 Eating Problems O 0 0 0 0 0 0 Boundary Issues ❑ ❑ 0 0 ❑ 0 0 Requires Night Care ❑ ❑ 0 ❑ 0 0 0 Education ❑ 0 0 0 ❑ 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 Ell 1--1 1'/z ❑ 2 Ill 2t/z ❑ 3 ❑ 3''/ 7 Weld County Addendum to the CWS-7/i (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE hi £ . Wu Aqe 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenance rl Rate Age 15-21...$19.27/day ($586/month) ra +Respite Care$.66/day ($20/month) $19.73 7 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) rfthlz CA $23.01 1 112 +$.66 Respite Care Tii Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2ili +$.66 Respite Care Total Rate=($30.25 day/$920 month) Dz $32.88 4,44 3 +$.66 Respite Care 11,4 Total Rate=($33.54day/$1020 month) Ila $36.16 il 3 1/2 +$.66 Respite Care NS Total Rate=($36.82 day/$1,120 month) 4lite $39.45 TRCCF Drop Down +$.66 Respite Care idriU Total Rate=($40.11 day/$1220 month) Assessment/Emergency 40 Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 Cler '� WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD 4;c� COUNTY DEPARTMENT OF HUMAN tart ; SERVICES '.nay lt By: //L/_ �Lil �: %A B371^7)S o one. lu-CJ Deputy erR to the Board / Chair ignature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Schmidt, Donald and Constance OF HUMAN SERVICES 937 Clydesdale Lane Windsor, CO 8055 By: By: irector By: 9 Weld County Addendum to the CWS-7A cws-in(rcro-IU/99) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENTIU Al' L 20 AN 11: 44 1' 1. THIS CONTRACT AND AGREEMENT, made this date, Aa ' /U 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, 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, 2010 and continue in force until June 30, 2011 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 LWb-/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-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 tot �: ��J WELD COUNTY BOARD OF SOCIAL 36t0c SERVICES, ON BEHALF OF THE WELD WELD�/ ' '•� OUNTY DEPARTMENT OF HUMAN it-' ERVICES By: y ! i /��Yr' k'`1rS B : Deput ler to the Board ' Chair Si nature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Sevestre, Lewis and Maureen OF HUMAN SERVICES 1717 69th Ave Greeley, CO 80634 {' By: et- By: �1 �GCl�2_'�� yJQL2� irector 3 ,7?C/(?c2/2 • 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, 2010 through June 30, 2011. The following provisions, made this /% day of ( )U/ „ , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of thgreement 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. • 761/1)-, ?/ 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 • (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 ❑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 ❑3'/r)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'/n)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'h hour per day ❑1%) '%hour a day ❑2) 1 hour a day 02 %) 1'/,-2 hours per day 03)21/2-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 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 03%)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond a2e 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%) II to 15 hours per week ❑3) 16 to 20 per week ❑3'/i)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 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-7. • (Exhibit B) WELD COUNTY DI-IS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a,di..,to this child. ` ". c'''�*o- iti 4 24 w ` s.�t t +r x �ni. �x'aM1d du At. bRk &. i ,- •F4 . '" 2- 4 - '''' ': � Tip "S`,` 4,'I'.' ^F � "t ' � .ri; "b".A's �� -""- 51.4-T"':‘ Zesi, b 9y� +ki2�Y.i-,4. -Li," - ' #'r:jig ' '' ',1%," }' `" d' S.- =`...41-,-7-. _ ti - . ''•,$a tt::'`a.� u�s.�L' „�Su;'X � ��.:%_"."... a .,f. k a",.�y,::.�r#cai'*v. Aggression/Cruelty to Animals ❑ O O O O O 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 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ 0 ❑ 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 0 ❑ 0 6 Weld County Addendum to the CWS-7, (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 r t c "»c y r .r&�A. ap v r,r t:v }y"v s a` Y a f., x.,uv y t '{,a' 4: e '#- `} y'S�rr�. .>. t ssa d»r�� s 3 :e .C.e...,.??..9,:,...� _ gyp: P". "" t ..' ' ,' ' _is Inappropriate Sexual Behavior 0 ❑ 0 0 0 0 0 Disruptive Behavior ❑ ❑ 0 0 0 0 0 Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 ❑ Medical Needs (If condition is rated"severe", ❑ ❑ ❑ El 0 ❑ 0 please complete the Medically fragile NBC) Emancipation ❑ 0 0 El ❑ 0 0 Eating Problems El 0 0 ❑ 0 0 0 Boundary Issues ❑ 0 0 ❑ 0 0 ❑ Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family ❑ ❑ El 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'/ 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE tIUUE1'iiPII 1, pc31�ti£35"�1,,S2 •�wid ktd Age 0-10...$16.32/day ($496/month) Crtil County Basic A.e 11-14...$18.05/da $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) tto 04 $29.59 2 1/2Kitt +$.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 5v $30.25 day/$920 month(Includes Respite) (30 day max) 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 yR�a.,. a. WELD COUNTY BOARD OF SOCIAL ]E Q,a SERVICES, ON BEHALF OF THE WELD % COUNTY DEPARTMENT OF HUMAN �_•.ti, �1 SERVICES l 1 W l -; -1 By: �°� Deputy .►?erk to the Bo�.� �� ha S gnature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Sevestre, Lewis and Maureen OF HUMAN SERVICES 1717 69th Ave Greeley, CO 80634 By: J By: hector By: 9 Weld County Addendum to the CWS-7A UWS-/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, Cu?a I�l 'MO by and between the Board of Weld County Commissioners, sitting as the Board m Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Shindle, Danny and Andrea, Provider ID#1550177, 1606 Fairacres Rd., Greeley, CO 80631, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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-/A (KIU-IU/99) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 LWJ-/A (KIU-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 WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD ..gyp . -, COUNTY DEPARTMENT OF HUMAN r. SERVICES ICI i $.7m: ' �� By: /,�i�i i !S/_%r:°::�l�Tti"D I a (lit- Deput 'lerk'to the Boa :�i, � ure SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Shindle, Danny and Andrea OF HUMAN SERVICES 1606 Fairacres Rd. Greeley, CO 80631 By By: it or / y Cl By: 4,4�!"C, LJape,' (:( 3 • WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the"Agreement") between Shindle, Danny and Andnid ja 21 P 12 42 and the Weld County Department of Human Services for the period from July 1,2010 through June 30, 2011. The following provisions, made this /r{ day of L.TaS , 2010, 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#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 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 ❑1)One round trip a week 01%)2 round trips a week O2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week O3%)7 round trips or more Comments: P 2. How 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 ❑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 01%) 'A hour a day O2) 1 hour a day O2 '/z) I'/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? ❑ 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 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 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 ❑2)8 to 10 hours per week O2%) II 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.) ❑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? O0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child. .. *.a, .'t r4iti +*nom tx ''1.,.......-+ ,, ,.J i,:.*: . ; .. ..�:'k,, r1 w cf '� x ,�A 43a b; 's;Ry{ R , t Fe z •'�'"� i.a... . r4 s5#.y * t ,A ryes .a'aem: is ,iiiit?,�whCi _ , .. . L3 #.. Y trim)1, .. ysa,."�?ssx ,E',g Jot. 8 4:Y.. .'. .. . .. .. .... ..', ax...,.:' .mot.x 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 Enuresis/Encopresis ❑ ❑ 0 0 0 0 0 Runaway ❑ ❑ ❑ 0 0 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ 0 6 Weld County Addendum to the CWS-7A • • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the b of conditions which create the need for services that a.8 I to this child. `f' ' ` i F behavior/intensi t,,. .� t51I;l,it t t ;8� §S0.R3 tx "K t o ry �M•£!'''RS A'2" £ ?5% ,'Y y Y c bb ut £ {d"'�'� �' 'ate �' ��i e++ � ,mv �aa. '' ₹ - w''$ a ,� �,}h' �` v?.?fr' M4r3: a'�" a° .s a r ,:11 s \ x z i 4 s ct 4 at. ,�''atin. �t'ri' ...,r kf a� *.'y ,t. .g r F , its e3t 45N kN -1 § Y#RR 7111' h )ask : F £ � 2m n. r A. Y.� x -ri, �� ;' y�} Six? ,z1,„'� : � � s G :: .i. , + ,3-N E3 �a W 4P t ,r ,:+ 4l yt :.;.,ii... ry, ₹.-`EL 49 , ar:: , �t;"sn'hx�,v xie,.,..L'aS�+k ..aSaa.s '‘a"`. . Ai., ..< . + .. :r9a� Inappropriate Sexual 0 ❑ 0 0 ❑ 0 0 Behavior Disruptive Behavior ❑ 0 0 0 0 ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ 0 0 Depressive-like Behavior O 0 0 0 0 0 ❑ Medical Needs ❑ 0 ❑ 0 0 0 ❑ (If condition is rated"severe", please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ 0 0 0 0 Eating Problems O 0 0 0 0 0 0 Boundary Issues ❑ 0 ❑ 0 ❑ 0 0 Requires Night Care ❑ 0 CI 0 CI CI Education ❑ ❑ ❑ ❑ 0 ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 El 1% ❑ 2 ❑ 2'A ❑ 3 11131/2 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE .r � y-`r L 'fi 4. t Aretii.44,4!;toil; t olvivir,s0Tcniimi•wlae-4 •. x q1`, �a if Age 0-10...$16.32/day ($496/month) County Basic ja4Age 11-14...$18.05/day ($549/month) Maintenancerg Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) pose $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 4.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.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) Lit 4 $39.45 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Rate ,.'4 $30.25 day/$920 month(Includes Respite) (30 day max) 3x; Effective 7/1/2008 8 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD gyp; COUNTY DEPARTMENT OF HUMAN .".422 SERVICES test 1 ,1sir By: i//[/ ♦ x.11%a%i ��il�l� vc, B • h area% Deputy ' lerk to the Bo Chair Si nature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Shindle, Danny and Andrea OF HUMAN SERVICES 1606 Fairacres Rd. Greeley, CO 80631 By: By: irector By: a`r ( 3 toyer arir 96 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 7010 JUL 19 ?? 1. THIS CONTRACT AND AGREEMENT, made this date, ) a i iO by and between the Board of Weld County Commissioners, sitting as the B rd 1 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 shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 o7ce - 2l %� CWS-/A(KIU-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 LINJ-/P.(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 th= :r' y( � WELD COUNTY BOARD OF SOCIAL ,�` � ¶ /�j` SERVICES, ON BEHALF OF THE WELD `I �� COUNTY DEPARTMENT OF HUMAN la SERVICES 'A � By: / /i///L/ . . �,�I��i,_I��.. 4 -ti � By: 1 21 CfYI Depute erk to the Boa' if ,?,�� Chai S'gnature Approval as to Substance: PROVIDER SEP 2 0 2010 WELD COUNTY DEPARTMENT Skeldum, William OF HUMAN SERVICES 5113 Saguaro Ct Johnstown, CO 80534 By: (.A./ By: irector By: 3 are-„;219Z- 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, 2010 through June 30, 2011. The following provisions, made this I day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms 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#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. 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 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 011/2)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 ❑l)Once a month ❑1%)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 DI)Less than a''/2 hour per day 011/2) 1/2 hour a day ❑2) I hour a day 02 %) 1'/-2 hours per day 03)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 ❑l)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 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 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. 02)Face-to-face contact two times Der month with child and occasional crisis intervention. O 2%)Face-to-face contact three timesper 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-7F • (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. £k ! �?t 4'�ny y, r*A�, k 4 •;',.4 : • k 1.1,u k•! - s` i f� y�pr y�: 1� h.IY#gy yY* �4x CCC f"�� ' • L 'iJe t' ! 6₹ t d � 'k'44+gh'r'� M�cb �`�+xz '*y :,S { � •} � ! u _ 4:. � (��4 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 ❑ 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 ❑ ❑ 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 - (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. Ifs 3 ` '$$&_ f t _ t' t x !: '�.',,t,::., x '` i ,,"'''k�:+. 12Ay h c J .,r } 4 ,,,,, ' _.£ fib ! ` ' i.. '� t - .1,1'-`,.pty', 4 ' #t 7�rc W.y 'k .;" }, 4h°,.'I 111;:! t.. Y 5.it. i ..14 t?&R T.4. yw,°,.R x g+ ENV. je �r .it '* "s. 9 � * 'f " tiir" x " a .,1— a§ , I �.: .; T ''" ° �` �. ... . ..'"^.'. i 4'� ,�..'"&'A'�Sg:..F.gv��"� ��wX4�r�4�'.:.k'.�e.vuae k gene. ...... .. .:" x_= _.,.. . . .z��5��&�.`�". Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ 0 0 0 0 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 0 0 Eating Problems ❑ ❑ 0 0 0 0 0 Boundary Issues ❑ ❑ 0 0 O 0 0 Requires Night Care ❑ 0 0 0 0 0 ❑ Education ❑ ❑ 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑l ❑ 1'h ❑ 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 e ;.,S a` sr c�kpry r fyyk ..eP4-k=' t S a1 • 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 4.66 Respite Care Total Rate=($26.96 day/$820 month) tasd $29.59 21/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care 11 Total Rate=($33.54day/$1020 month) aft $36.16 3 1/2 +$.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 Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 nal t By:/ r" �y d S/: e �'� B Deput ler to the B `/ �°� � Ch it ignature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Skeldum, William OF HUMAN SERVICES 5113 Saguaro Ct Johnstown, CO 80534 By: lOl By. th"-c 'rector vvv 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 AGREEMENT I dolt 1. THIS CONTRACT AND AGREEMENT, made this date, JILL(-1 ito 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, 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, 2010 and continue in force until June 30, 2011 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 (K I U-I U/99) 4 ' 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 LWa-/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 La WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD y �t►' ' o„-.`,,,. .� COUNTY DEPARTMENT OF HUMAN 161 1t ti�•: SER ICES yin We By: Deput / lerk to the Boa ha Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Steele, Dana and Cassandra OF HUMAN SERVICES 324 Fossil Dr. Johnstown, CO 80534 By: By: Gyiic - Dir tor By: 3 arc /D 02/ %O, WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Steele, Dana and Cassandra and the Weld County Department of Human Services for the period from July 1, 2010 through June 30,2011. The following provisions, made this /fday of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms t 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#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. 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 O2)3-4 round trips a week. ❑2''/)5 round trips a week O3)6 round trips a week O3%)7 round trips or more 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 ❑2'/)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 ''/z hour per day ❑1%)'%hour a day ❑2) I hour a day O2 %) 1'/z-2 hours per day O3)2'A-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 DI)Less than 5 hours per week 01%)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%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) DI)Face-to-face contact one time per month with child and minimal crisis intervention. ❑11s) 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. ❑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%n)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) DI) Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behaviorhntensl[ of condrtlons which creatte the need for services that a..I to this child u} i }Y" int J c4144'7ys ;"d'atx�'d ,. t � s. .y $" •' ¥ytR a _. y.44„,141,10,"rw : is `w,2 ';44$1,14,•:1'.1.''.4•L".' `a :'v r4��,44 4.‘%;',14;!-R.1-ii-N.41 3 1,41 f Ff � : l�ell '. M } ` s a ! 'skf r-; } ;!- @ a ! A. ,4 ; ` °'is..7 r.}ay• .w x 5`"' {�,`?' x"° i a :q„'`. {,t,a 4 : Y 1$3 'v i t f n n��6 >l qn, .. ,4se" ry 5£ C 4 92 $' �, t P., 1 i'}i 4 .4 4 m ¢ k�ai a € ?- ; l '-fit b _f )s"m.' a.w ..;. a a_,. ,, .... . :aA' , ':: Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ 0 0 0 Verbal or Physical Threatening O O 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 O O O Stealing 0 0 0 0 0 0 0 Self-injurious Behavior O 0 0 0 El 0 0 Substance Abuse ❑ 0 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 ❑ ❑ 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS-7A ' (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..I to this child. raw"" '...-i " _ # `� L : 3v s 4." s ifs "4"*..u' eb t . .„-i '.z.. b y S: £? k 1.!r:. i'..,',.;' , t '-?''' kf§tt lc'',”.4-.1-3..f § 4 7ia'Z'ICIT1;11.).-11 . to trn # I cZa ff •.'s p tg;.d`n s' ;;,s l'4 � 'f ey,$ a� a ;(_d '�a S" .rq�a&.`. ,.aCs:�.k ri�s3� .�..�„.':* . Ft , Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior O 0 0 0 0 0 0 Depressive-like Behavior ❑ 0 0 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ ❑ 0 0 0 0 0 Requires Night Care O 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/4 ❑ 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 r r �y • •y - T ..At<St�'dsst`�rf tgni y'Ri r �� • • +g•,i4 •, •, 5F ai • hgtx Aqe 0-10...$16.32/day ($496/month) County Basic Aqe 11-14...$18.05/day ($549/month) Maintenance Rate . Age 15-21...$19.27/day ($586/month) e?' +Respite Care$.66/day ($20/month) $19.73 1 - 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) h s $23.01 1 1/2 +$.66 Respite Care { Total Rate=($23.67 day/$720 month) 241 $26.30 2 `E +$,66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) Yt IL" $36.16 3 1/2 d +$.66 Respite Care 3E Total Rate=($36.82 day/$1,120 month) yA;rzl 4 ,.�.3i§ $39.45 TRCCF Drop Down a +$.66 Respite Care w Total Rate=($40.11 day/$1220 month) Assessment/Emergency Rate $30.25 day/$920 month(Includes Respite) (30 day max) 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 t.y ::.: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By �% /' ��•.' �i-- a�~ �, B Deputy,►erk to the ��,:��' � Q4/9-7.9,147-1 Signature SEP20nip Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Steele, Dana and Cassandra OF HUMAN SERVICES 324 Fossil Dr. Johnstown, CO 80534 t By: By: j<- , irector By. _ - , .2c/n - a?/94 9 Weld County Addendum to the CWS-7A (K 1U-10/99) 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, 010)"AiS/SD PI by and between the Board of Weld County Commissioners, sitting as the ar f 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, 2010 and continue in force until June 30, 2011 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. I aCrD D2196 l6 LWJ-/A(KIU-IU/99) 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on-going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 LWJ-/A (KIU-IU/?9) 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 -'� / SWELD COUNTY ERVICES, ON BEHALF OF SOCIAL OF THE COUNTY DEPARTMENT OF HUMAN WELD By ` �.Deput lerk to the Bo��y Chair ignature Approval as to Substance: PROVIDER SEP 2 0 2010 WELD COUNTY DEPARTMENT Steitz, Daniel and Natalie OF HUMAN SERVICES 1701 Elder Ave n Greeley, CO 80631 By:c- 6I By: lea Directo 3 ar/r-- �/ %� WELD COUNTY ADDENDUM 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, 2010 through June 30, 2011. The following provisions, made this 1 day of Imo_, 2010, are added to the referenced Agreement. Except as modified hereby, all terms of a 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 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. ( E)/Z5-- 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 01)One round trip a week 01%)2 round trips a week O2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week ❑3%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 O2)Three times a month O2%)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? O Basic Maint.)No educational requirements ❑1)Less than a ''/z hour per day ❑1%)'/z hour a day O2) 1 hour a day O2 '/z) 1'/z-2 hours per day O3)2'/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? 0 Basic Maint.)No special involvement needed ❑I)Less than 5 hours per week 01%)5 to 7 hours per week O2) 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 ❑1%z)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 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. ❑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? O0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child. '� 'fit "$ , , ,424 ',4''t- s t a '10--.21:1421,1:;;44::%0W-° 9:"1 e t Y.4i'2a >".' � - A { .. � + �' v§i7$i �n^ a, o-§� �a vyt s • a+. -4.,:. . r+,-.'�y''�° t— 'a§�*j'::::' fix} h �a . ' . 3 11:.'hit.;:iretit:;titmtie UT st; ,-.€., t'4 vw1 3 m - � a%a a' + ' g "r te c.*. J:i��5. tn.:.:-.z.--- —a. a&' ''��..k�:o..�i3.,. ..:°.. a•c_..:. ..,.. .:, . ...B. .. we Aggression/Cruelty to Animals 0 0 El ❑ ❑ ❑ Verbal or Physical Threatening ❑ El ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ 0 0 0 0 0 Self-injurious Behavior ❑ 0 0 0 0 0 0 Substance Abuse ❑ ❑ 0 0 0 0 El Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ 0 0 0 0 0 Runaway ❑ ❑ 0 0 ❑ 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS-7A . • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..I to this child. ': ?J':- ' "aa .$ 'h:'h+,Y �'. Y ?., +.gy r ar,^. r. , 'v . w,,,,,„•...:,r ..:i.c. , " �z ' l” n 3:i8q�t4 rVtaa w " v e, as * _ "' s t . 'c a fitit4v n V '' - eL `` `rfro,n ,thii0A'Of�'L Y �' i� v3, ":�""�, :''1�e -° ri `3'+44 'fi4 i�yteT w'^}�"'sb. ...,i y .,� a rya a d t s r 'as..3^,. � � ��§ f acs ,a��" ,r r x�,t„+��i� &x � v..'14. a�'+xi � � n � � �v -- !i_..P. "' c-s` Vai i•t':.G'6" r r'"�;j ',. :. `'h..a.a°. _ ..",. $s+c. ,. .a.c. ..th.“_. :-...: +... .u.z$a! Inappropriate Sexual Behavior ❑ 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 Medical Needs (If condition is rated"severe", ❑ 0 El 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ ❑ 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2'/z ❑ 3 ❑ 31/2 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE m t ." 'y.c Y i w a a: ' S / •zr ya:•,"S 4111 A.e 0-10...$16.32/da $496/month 1,40 County Basic Ase 11-14...$18.05/da $549/month Maintenance Rate A•e 15-21...$19.27/da $586/month +Respite Care$.66/da $20/month 5.111 6114 $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) TT • $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) r44- $29.59 21/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 112 'Alf +$,66 Respite Care Total Rate=($36.82 day/$1,120 month) $39.45 4 TRCCF Drop Down +$.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment/Emergency Rate lig $30.25 day/$920 month(Includes Respite) (30 day max) Nal Effective 7/1/2008 8 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk WELD COUNTY BOARD OF SOCIAL 6' SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN uki• °'' SERVICES By: ��il_ !�� ;s-; e,,., DeputyA►�erk to the Boo'ar�� Ch it ignature SEP202010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Steitz, Daniel and Natalie OF HUMAN SERVICES 1701 Elder Ave Greeley, CO 80631 By: By: (---/L-_—)( i ctor By: ._.'L-' J �t� cQC/n--9/%h 9 Weld County Addendum to the CWS-7A � .... ...�.�... ....iii • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT1 1. THIS CONTRACT AND AGREEMENT, made this date, ! A DID by and between the Board of Weld County Commissioners, sifting as the Bo o octal Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Van Den Elzen, Dawn, Provider ID#44282, 7219 W 20th St Ln, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 o?E%/(' />�n LW -/A(KIU-lU/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 y� ^ 1 WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES 1661 • By: /i.L//it ALPO y i ' B isL"' Qgnature v1P AteDeput lerk to the :�� (/ ti SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Van Den Elzen, Dawn OF HUMAN SERVICES 7219 W 20th St Ln Greeley, CO 80634 BY ( Dfrectorq' tJ By: 4atzen rr��»v By: 3 aric-a/' 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 1,2010 through June 30, 2011. The following provisions, made this 1 day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms o 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#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. 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 (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. ❑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 ❑2'/)Once a week 03)Two times a week ❑3'/)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑1)Less than a '''/ hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 1/2) 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 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? ❑ 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 ❑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) 0Basic 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%:) 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 02)4-8 hours per month 03)9-12 hours per month 5 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..ly to this child. '. il+"y 7: ,y' :?TO.' n s.x ^ t;v ! a lux p g : 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 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 ❑ ❑ 0 0 ❑ 0 0 Runaway ❑ ❑ 0 0 0 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7A S-7A (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions FT, r- ''i .. i k..t : . cs f:itilith ."` i,yh'-. ....2. �i,-'z,' .. F *.5241 4 y .}' tt, d t "t ' 114:i s s�: > ° ° � . �' '°rt" p. '� Y $ h -1 ti--- 9 A ,v.. J : • § `:k •::),;i.- ve ry{' w �s-�.a. z +Ty "�:�Y t n. rv� x ,mo ¢ + a e 5`�: 'v�� A tt�`�;r . � r"#'.�. k:m5'Xu'�µ;_ '�� ..;-. ' .r'.�' r' 1r u:* -p•sa, s t�'* '*, `3°p +' ' t ,.,°,a "` rMy' ° ''a as.. t 5 `' � ' a : dr'. r x- '% a; 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 0 Depressive-like Behavior ❑ ❑ ❑ ❑ 0 0 0 Medical Needs ❑ 0 0 0 0 0 0 (If condition is rated"severe', please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ El Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ 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 0 0 0 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ri❑ 1% ❑ 2 El2'/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 ';)7 °sst Pb. ,R .�gy>fi hb :„, „,,,t,,,,,,,„,,,,,„:„,..„:„:..:,,,, ,,,,,•.-\!„,:, pn.,w,,,k,:wti.TitQa,Ez„:.4,,,,,,,,,,,,,z,„...,T:,,,y.,,,,:-.,::H.,T_,.,„,,.,. ... .. „ .,..„:„:„.„.„:„.,„,„,„,,,,..„.,,,;:,,,:„.,,,„.,...„.„,„,,,,.,,...,,,,„„.. ..„.„,,„.,,th .., ,,„,.. „...,...,.....„.„,,,,,i,n k,.:ll'A!,hyYttha,14.42,j'erityMt4tnr.LZ.,.:4410t,m-.tff,f, ,,tlly,-.,y1 se kitt Age 0-10...$16.32/day ($496/month) County Basic 0,1 Age 11-14...$18.05/day ($549/month) Maintenance la RateJAH Age 15-21...$19.27/day ($586/month) fii +Respite Care$.66/day ($20/month) lid $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) km $23.01 1 1/2 ttra., 4.66 Respite Care Total Rate=($23.67 day/$720 month) ii $26.30 2 +166 Respite Care Total Rate=($26.96 day/$820 month) F. $29.59 21/2 +$,66 Respite Care Total Rate=($30.25 day/$920 month) I $32.88 3 ,txtm +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 31/2 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) Pi Assessment/Emergency tip Rate 44 $30.25 day/$920 month(Includes Respite) (30 day max) 12 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 •*;et ;�� WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD • ! � �, COUNTY DEPARTMENT OF HUMAN ;,��.._ 1�1 1 t c SERVICES •By: By. Deputy M erk to the Board Chair Signature SEP 2 0 2090 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Van Den Elzen, Dawn OF HUMAN SERVICES 7219 W 20th St Ln Greeley, CO 80634 By: By: L2s-7 ! I./,,,, , ector By: 9 Weld County Addendum to the CWS-7A UWS-/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,0-7/P-0 2,O I D 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, 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, 2010 and continue in force until June 30, 2011 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24-hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 o?E/e_„2 %). l-WS-S-/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. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out-of-home provider. 2 ' • 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Cl- k to.Ifldt . WELD COUNTY BOARD OF SOCIAL J5 ® \ SERVICES, ON BEHALF OF THE WELD / �V �, COUNTY DEPARTMENT OF HUMAN ?� SERVICES A By: /.i/// Bye Deput Clerk to the B�5`:' •-ir signature Approval as to Substance: PROVIDER SEP 2 0 2010 WELD COUNTY DEPARTMENT Vincent, Jessica and Ryan OF HUMAN SERVICES 4910 W 2nd Street Greeley, CO 80654 By. By: V A"c-sue 'rector BY: - UVW� 3 0 C1C a/9 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, 2010 through June 30,2011. The following provisions, made this 14- day of JiA ( Ut , 2010, 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. 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 ❑l)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 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 ❑1'%)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? 0 Basic Maint.)No educational requirements ❑l)Less than a ''/z hour per day 011/4) 1/4 hour a day ❑2) 1 hour a day ❑2 %) 1''/-2 hours per day 03)2''A-3 hours per day 03%)More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week ❑1%z)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 01)3 to 4 hours per week 011/4)5 to 7 hours per week 02)8 to 10 hours per week 02%) I I to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week Comments: A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑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%) Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑l)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 5 Weld County Addendum to the CWS-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..ly to this child "Z.kt. n"' e '7, ' "'s 7 fit, ' ^,. , y tw ', " +1 i x s • r _ ':;----,";',...--..c: filc4.k.)::::::,*-,3;5"tijiggli'l;:',$/iiV.-":",',41::::::"•::',{7;;,..?:".- ,-. ' '''.'T..7.),-.,:t:t'..'''.! :''''' '", .,/,'''i ' "' ' '' -.."' ' ' .--Itir' .'. 1 •I';"!:4'g•7:1 iltrigic?.;;•; rte, y. .xQ 3: k 'u.d^4 M?: t i § :W Sk?; ` .mrrx.:v wrk;,::,-t,;4 ai:.vi,,,,' axs...i.d; 2N .5,,eflrf,,r r, -vv 3". y .. , e i ' : 4liti � s",i4:::::; 4:aa x t 4Vel9C1.T.0x3-• §. ,.yc ,„.• ; ", s r .. ',-'� k�. tF" , r4 Z' S.e+=Ya . •'`3"xY� � .;-t .... .. � 3-_ ._ §":":. 1:ii Ite31..-..ak.;;S:is., .s °.tic .,,x, A:rd .0 1, .. . .x st. : Aggression/Cruelty to Animals ❑ ❑ 0 ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ 0 0 0 0 0 Substance Abuse ❑ ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis O 0 0 0 0 0 0 Runaway O 0 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7. (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..I to this child. u�5� � m ` M'" f zH i�}"s '5''"ai s"4*b'�6,�:' sc4�✓ ``'�' �.. �� P c t ?;# rg,x'4� FS"� ,: E,.. �.1:A v 4 r .; pt$a.lia 'z7ua. e "'$ z di+ i s 5 yag' '5..t 'fe1' !v.'. a.� b„ +, t...'„s �;'�'1-, y v`ai'n kJ"}#i� fa.I G$ 141:,,:01 3'` .y 447 !•::::,.-:::'?':::4,c4”;.17;w:y0;yV x • 1.“ , "fie. .,._ .� 4'.a.: itil' Z,;...'" i irtzle C..`_ "W'49S#". c 'x. 3#.'?" •.k-;;Air .L. s. _.- . . �. ..... ..c%... . ,.'* `..a' s. 5 , Inappropriate Sexual Behavior ❑ 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", ❑ ❑ ❑ ❑ ❑ El ❑ please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ 0 0 0 0 0 0 Education ❑ 0 0 0 0 0 0 • Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑l ❑ 1''/ ❑ 2 ❑ 2'h ❑ 3 ❑ 3'/2 7 Weld County Addendum to the CWS-7A (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE obi A.e 0-10...$16.32/da $496/month County Basic A.e 11-14...$18.05/da $549/month Maintenance MO 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) $29.59 2 1/2 +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) 0..414 $36.16 3 1/2 +$.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) (30 day max) Awi 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 ERVICES 361 Deput ! lerk to the Bo\ �/ki ii O / Chair Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Vincent, Jessica and Ryan OF HUMAN SERVICES 4910 W 2nd Street Greeley, CO 80654 By: By: fr a„ 'rector I / By: .7� V4- V\, Cg)-ai5 ; 9 Weld County Addendum to the CWS-7A I.wa-in knhV-IV/YY) INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, At 1 Li, I kt by and between the Board of Weld County Commissioners, sitting as the Board otSocial 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, 2010 and continue in force until June 30, 2011 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 07O/O a �9 LWS-/A(K1U-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 LWS-/A(K1U-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 l eta WELD COUNTY BOARD OF SOCIAL a' SERVICES, ON BEHALF OF THE WELD 4tf, COUNTY DEPARTMENT OF HUMAN .? •�, SERVICES 1861 1 1 : ., By: I/il//l �•1 /►�•.��', _ -�. By i,L ra Dep • C erk to the ChSiilnature ``'��-�►� SEP 2 0 2090 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Wade, Michael and Jodyne OF HUMAN SERVICES 1016 Cottonwood Dr Windsor, CO 80550 By: jCiltylL, By: ctor it 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 Wade,Michael and Jodyne and the Weld County Department of Human Services for the period from July 1,2010 through June 30, 2011. The following provisions, made this )1-1 day of J{t\� , 2010, 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. CRC/C-c / - 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 (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P I. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑l)One round trip a week 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 03%)7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? 0 Basic Maint.)No participation required ❑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 ❑2) 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 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 ❑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.) ❑I)Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/z)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 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 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/ (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. it f ^se • a ..E.1 a' .. §-, h, T 9+ W• } y `Yk ° 'v .` ;i. a,x• Q t 4.:4'44,1; vJ x '� "assM0l 44 �x'wt yy• e� a t*ti -. A.c p I; a il a kRa .cv C ey,ler* I e+y F et '4 .!,:* •'tA '$ 4:. ',y•.11;',4y, A�...k„ o€,an k.v "w�..,fra h.a�. „a'5k.., .&.aa ' .k�„'S.iiSr>v..,a . .. .. ., . _• .a, x .�. , ,..a.:" „a ,',, Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ 0 0 Verbal or Physical Threatening ❑ 0 ❑ 0 0 0 0 Destructive of Property/Fire Setting 0 ❑ ❑ 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ 0 ❑ ❑ ❑ 0 0 Substance Abuse ❑ ❑ 0 0 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 0 ❑ 0 0 ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ❑ Runaway ❑ 0 ❑ ❑ 0 0 0 Sexual Offenses ❑ 0 0 0 0 0 0 6 Weld County Addendum to the CWS-7A (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a...1 to this child. 3i in." ' „t ++,`.,,ux ?,v,,. v w r: 'v :2 wr 1 3 (1 ;.' : mod . �.,a. f d ,, t i. ira ,.i, ku R 7x T , 5 }. Y t n� „�,c i,ss, a � � 1.- bt.. °vt sy x ...1'. ..2y..-'' r s °F 9 �t y va �' 4-'`ig- 'r $TI$14 t ` .,... ,g4 ;`y. x c x�v t; Inappropriate Sexual Behavior 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ 0 0 0 0 0 Boundary Issues ❑ ❑ 0 ❑ 0 0 ❑ 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 El2 ❑ 2'/2 ❑ 3 El 31/2 7 Weld County Addendum to the CWS-71 (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE tar LAIL'.7,3Sy 1 N Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maintenancerti Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 +$.66 Respite Care :5.71: Total Rate= ($20.39 day/$620 month) tist $23.01 1 1/2 +$.66 Respite Care 0404 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) iitot $32.88 3 +$.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 Ix Rate $30.25 day/$920 month(Includes Respite) (30 day max) Effective 7/1/2008 8 Weld County Addendum to the C W S-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 Cle ft ,~'•a�, WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN 1861 413.44 SERVICES By' �✓/ / i� _.�_1%�y� f^vtc. B Deput Clerk to the Bo''-��'� hair Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Wade, Michael and Jodyne OF HUMAN SERVICES 1016 Cottonwood Dr Windsor, CO 80550 By B • irec �I By: 464, /Ll 02110— (2/fl 9 Weld County Addendum to the CWS-7A UWS-/A(KIU-IU/99) t • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, Pus \ s+ zott 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, 2010 and continue in force until June 30, 2011 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 02Cei 2 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-/AtKIU-IV/99) 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. La ATTEST: Weld County Clerk to d-'•,r� Las, WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE COUNTY DEPARTMENT OF HUMAN WELD SERVICES tee . By: I%// _L . ��1 /i:.,: �; 1y u I By: cA C/ Deput ler to the Boar ��r .# /ChairZI? øioiii re Approval as to Substance: PROVIDER SEP 2 0 2010 WELD COUNTY DEPARTMENT Walker, Kurt and Jennifer OF HUMAN SERVICES 519 Trout Creek Ct Windsor, CO 80550-3194 By: By: irector By: —Q.4--,;-4. • X6 _ 3 opre-o2/%, 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, 2010 through June 30, 2011. The following provisions, made this day of LA.. i; 2010, 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. O2O'7'-c 19 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 (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.A)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? 0 Basic Maint.)No participation required 01)Once a month 01%)Two times month 02)Three times a month ❑2'/:)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''/3 hour per day ❑1/)'/:hour a day 02) I hour a day 02 /) 11/2-2 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 ❑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 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 ❑1/)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%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 Der 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) 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 (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that al.1 to this child. FeG y,ry �,'k",�.t ''i 'i"MA IMY. s",.f: b9 t# _5 r, !. 4 ;,,Rll " '7"1;43.M. ✓' # �n t..�7.�s x x,,y ,.s"4 5 + s + , „ eM it .L. i, 9 ✓drat i. w sy-� . s }4 s& w 't4u ::::,,,..,:;;Ti.,: i„...,..,. s 3. Aggression/Cruelty to Animals 0 ❑ ❑ ❑ El El 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 Enuresis/Encopresis ❑ ❑ 0 0 ❑ ❑ ❑ Runaway ❑ ❑ 0 0 ❑ 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 Weld County Addendum to the CWS-7A • (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that as 81 to this child. clirt'Psitllehtiis!''s y f 4.Try s.s ,. @#{; +:may f] 3t'h &4'knw:u, �` -1��sf� i Y ..,...s,„.:e,,u' .. A F � � � • ¢ , 4n i a :..-.: '..s" ` a . .�, e a `` f }*aa a �x'° f^t"` % * A 4�&�4r r� -'w ,' y'�`5�+�£g'.,a�"- '' zs�[8.a� H �° '�a*� ant S �.�„n S ,+{�'�h�. ' ' `'tea ys:b'+ a y f4 s 's r 3 ::::::41e(,'7: 's,. Inappropriate Sexual Behavior ❑ 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior O 0 0 0 0 0 0 Depressive-like Behavior O 0 ❑ 0 0 0 0 Medical Needs (If condition is rated"severe", ❑ 0 0 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ 0 0 0 0 0 Eating Problems ❑ ❑ ❑ ❑ ❑ 0 0 Boundary Issues ❑ ❑ ❑ 0 0 0 0 Requires Night Care ❑ ❑ 0 0 0 0 0 Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 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 t flfl { yaq�t rh t'� g7„ft 3+'a s { Est, xa,1 kty2.4,4 Age 0-10...$16.32/day ($496/month) Rtr County Basic Age 11-14...$18.05/day ($549/month) Maintenance Rate A.e 15-21...$19.27/da $586/month +Respite Care$.66/day ($20/month) $19.73 1 +$,66 Respite Care Total Rate= ($20.39 day/$620 month) eit $23.01 1 1/2 +$.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) ;77: $36.16 3 1/2 +$.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) PIN T:r Assessment/Emergency Rate "`' $30.25 day/$920 month(Includes Respite) (30 day max) to =aia 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 By:'Lail B dnna Deputy Jerk to the Board it Signature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Walker, Kurt and Jennifer OF HUMAN SERVICES 519 Trout Creek Ct Windsor, CO 80550-3194 By: By: irector By. aC7C-a/94 9 Weld County Addendum to the CWS-7A L WS-/A (.K I U-I U/99) • INDIVIDUAL PROVIDER CONTRACT • FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY nn AGREEMENT 37) 1. THIS CONTRACT AND AGREEMENT, made th&id 6 34 Of OW by and between the Board of Weld County Commissioners, sitting as the Bo d at7Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department"and, Willert, Melody D and Lee, Kimberly, Provider ID#1540372, 219 N 4th St, LaSalle, CO 80645, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2010 and continue in force until June 30, 2011 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 &r,c - a i r�- I:WJ-/A(KIU-IW99) 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 UWS-/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 Clerk to sf�'i•:Yr1 Las WELD COUNTY BOARD OF SOCIAL COUNTY DEPARTMENT OF HUMAN WELD Iasl SSEERRVVIICCEESS, By: dkn r 0. I Byes .tea Deput ler to the Boar."a.. _.rte Chai ign ture SEp 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Willed, Melody D and Lee, Kimberly OF HUMAN SERVICES 219 N 4th St LaSalle, CO„ 80645 By: O By: f_) t� irector By: ��' ; A 3 c CC/C>- /9(r 4 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 1,2010 through June 30,2011. The following provisions, made this 1 day of , 2010, are added to the referenced Agreement. Except as modified hereby, all terms t Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1540372. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. &thi- 9/9 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 (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'/)2 round trips a week ❑2)3-4 round trips a week. ❑2%:)5 round trips a week O3)6 round trips a week ❑3/)7 round trips or more 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%z)Two times month O2)Three times a month ❑2%z)Once a week O3)Two times a week ❑3'/)Three times a week or more Comments: P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements ❑l)Less than a '/:hour per day 01%)'A hour a day O2) 1 hour a day O2 %:) 1'/r2 hours per day O3)2'/:-3 hours per day ❑3''A) 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 ❑3'/)Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? ❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week ❑2) 8 to 10 hours per week 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.) 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. O2)Face-to-face contact two times per month with child and occasional crisis intervention. O2'A) 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 (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. ' � #t.4''r ya°+ua` s`er ' i 3a ,t h is et s- . w .cx*�� - * h- g ''etr, .1 'sup e #}a s,. ::. ... ..41.c .'S !, "'r bl ,*a e' ;Alike. ` k '? c :" '.1--"w''''."#,x4i.:`-..“.; s nom` "4 '' k ? • ' , ... r a �yi ,. a a ` .mr t,:,1'to '''''`. p';,,a i • wt.aye t. ,,} C ty.97 x ` X .".".....:4 ai*w ,. x s. u s,,qr .., gv'� 3.: r°�y. ... a '� '��.�� `k��.':>Nsi`R65es'�»' � � v� f .,�5+.:d - . . �x .. .... ek �.��wA Aggression/Cruelty to Animals ❑ ❑ ❑ 0 0 0 0 Verbal or Physical Threatening ❑ ❑ 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ 0 0 0 0 0 Substance Abuse ❑ ❑ ❑ 0 0 ❑ 0 Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑ 0 0 0 Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ 0 Runaway ❑ ❑ 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 6 Weld County Addendum to the CWS-7A S-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 ar rly to this child. .,,,,,...g;,..,. � ,=�p,� • `avio ` Sa ia,'` .v' t` ie,r1 r , 4t i x a ,,:,),I,"..:::::7,,;4::: �'yia i �k' ':s .g �# &ktn t a+i<k .i V ;:'' . . r ti -.v r:y g' u' j1.+ .w'.... aSu S .4i,1* f4 �.:... * 's s. s �,v'. 1'` �w S`4�' ' i y ztv u� '-c 4 ' 5 h'r.1-6%%° °thy ` ""::),, � re � ° L'£ 1. I h h R i , e" I i. �, 7k: t: v '+isk Y .', t r fir,1. .4., ','-.^'4' bs �d! .±b& fxib a t � :a.r _:,°a: �F :s1 r k=h, ,:...,-.,.°t,- ,a,.. .c.� < Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior 0 0 0 0 0 0 0 Delinquent Behavior 0 0 0 0 0 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ O O 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ 0 0 Eating Problems ❑ 0 0 0 0 0 0 Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ 0 Requires Night Care 0 0 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 Ell ❑ 1% ❑ 2 ❑ 21/4 ❑ 3 El 3% 7 Weld County Addendum to the CWS-7A . (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE x 1 ,:,,�c•q ° ��k �'�� a st ° n �,`.3 u::2;74„'S '7.1'3w 1': :411tH.*Y-: '8 `{ _ ). X14 2 u 1.� % A2 : .. 1`.. 1Iiiiiffeatititikkaliiii:X.4,41Velilik 'iik; !"4:7;:1.:1S Age 0-10...$16.32/day ($496/month) County Basic kis Age 11-14...$18.05/day ($549/month) Maintenance Rate Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) $19.73 1 4.66 Respite Care Total Rate= ($20.39 day/$620 month) osi $23.01 1 1/2 pi 5t4". 4.66 Respite Care Total Rate=($23.67 day/$720 month) Apo $26.30 2 +$.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) DA $32.88 3 4.66 Respite Care Total Rate=($33.54day/$1020 month) hi $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 Rate ti $30.25 day/$920 month(Includes Respite) ak (30 day max) ,c-.! 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 Cler. t : : �a�► WELD COUNTY BOARD OF SOCIAL , 4` SERVICES, ON BEHALF OF THE WELD • COUNTY DEPARTMENT OF HUMAN ism l tat" - � SERVICES Rib By: ii//lL ., . � �/��,<./_.:�A B • Deputy lerk to the Boar?" Chair ignature SEP 2 0 2010 Approval as to Substance: PROVIDER WELD COUNTY DEPARTMENT Willert, Melody D and Lee, Kimberly OF HUMAN SERVICES 219 N 4th St LaSalle, CO 80645 cc By. By: R y irector By:j\,"r --,U-,A.A F, L a S1 (z/D-S /SJ 9 Weld County Addendum to the CWS-7A Hello