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Home My WebLink About20102300.tiff MEMORANDUM fli 1.116 DATE: September 27. 2010 Ii`PC TO: Douglas Rademacher, Chair, Weld County Board of Commissioners COLORADO FROM: Judy A. Griego, Director, Human Se es ep rtment RE: Weld County Addendum to Purchase hild Placement Agency Services between the Weld County Department of Human Services and Various Providers to be Placed on the Consent Agenda Enclosed for Board approval are Weld County Addendums to Purchase Child Placement Agency Services between the Department and Various Providers. These Addendums were presented at the Board's June 21, 2010, Work Session. Please place on the Consent Agenda. Below are the major provisions of the attached Agreements: No. Facility Name/Term Type of Facility/Location Daily Rate 1 Adoption Alliance Group Home/Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Denver, Colorado 2 Ariel Child Placement Agency Group Home/Foster Home $16.32-$40.11 July 1, 2010— June 30, 2011 Wheat Ridge, Colorado 3 Commonworks DBA Synthesis Group Home/Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Arvada, Colorado 4 Hope & Home Group Home/Foster Home $16.32-$40.11 July 1, 2010—June 30, 2011 Colorado Springs, Colorado 5 Imagine Group Home/Foster Home $16.32-$40.11 July 1, 2010—June 30. 2011 Lafayette, Colorado If you have any questions, give me a call at extension 6510. 7? hie6tAF/ 9_,,2.9--,-,20/0 q _p*_ I 2010-2300 6 DEPARTMENT OF HUMAN SERVICES ctioP.O. BOX A GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 • COLORADO MEMORANDUM TO: Judy Griego — Director FROM: Lesley Cobb - Child Welfare Rate Negotiator DATE: September 22, 2010 SUBJECT: The Weld County Addendum to the Agreement to Purchase Out-Of-Home Placement Services contracts for Child Placement Agency Services. Attached please find the Weld County Addendum to the Agreement to Purchase Out-Of-Home Placement Service Contracts for Child Placement Agency Services for following providers: Weld County Child Placement Agency Providers 2010-2011 'x:4% E 4�+ .' 1 Adoption Alliance 71259 2121 S. Oneda St, Suite Denver, CO 80224 420 © A.lencChild Placement 90205 4251 Kipling St, Unit 5002899 Wheat Ridge, O 80033- Commonworks, DBA 104085 5310 Ward Rd, Suite G- Arvada, CO 80002 3 S nthesis 01 4 Hope & Home 29867 1925 Dominion o0 Way, Ste Colorado 809Springs, CO 18 © Imagine 21369 1400 Dixon Ave Lafayette, CO 80026 These contracts have been presented for consent approval to the Board of County Commissioners however; I am requesting your signature along with the Boards to complete these contracts for the FY 2010-2011. If you have any questions please call me at Ext. 6441. • WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Adoption Alliance and Weld County Department 1 of Human Services for the period from 'r4A July 1,2010 through June 30,2011. The following provisions, made this j day of 7 , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the CPA identified as Provider ID#71259. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with family members, medical/dental or mental health appointments, extracurricular activities, court hearings or other specialized programming. Transportation expectations will be documented on the Child Specific Addendum, SS23B. 5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 6. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 7. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays,the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. Weld County SS-23A Addendum • 8. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Service Utilization Unit. Contractor shall be notified by County staff of the date and time of the review. 9. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 10. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Contractor. All documentation of these examinations shall be forward to the County. 11. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student every 3 years and coordinate reviews every year. If the IEP is due while the child is in placement, the Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to the County. 12. Add Paragraph 18 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 13. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 14. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 2 Weld County SS-23A Addendum • 15. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 16. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 17. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s)to the Human Services' Director. The term"litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 18. Add Section VII-EXHIBITS: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX ITRAILS CASE ID IDOB M F WORKER COMPLETING ASSESSMENT rATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? ['Basic Maint.)Less than one round trip a week DI)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 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 ❑3%)Three times a week or more P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements DI)Less than a'/x hour per day 01%)1/2 hour a day ❑2) 1 hour a day O2 1/2) 1'/2-2 hours per day O3)2'h-3 hours per day O3%)More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1%)5 to 7 hours per week O2)8 to 10 hours per week O2%) 11 to 14 hours per week ❑3)Constant basis during awake hours O3%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond 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 O2%) 11 to 15 hours per week ❑3) 16 to 20 per week O3%)21 or more hours per week A I. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 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%)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 4 Weld County SS-23A Addendun (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. ro x K - ar - e Aggression/Cruelty to Animals ❑ 0 0 0 0 0 0 Verbal or Physical Threatening ❑ 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ 0 ❑ 0 0 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ ❑ ❑ 0 0 0 Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 5 Weld County SS-23A Addendun (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. d{f}F"'^..4 ^ rte '&; s t +wk '}^ d₹ t, Y- I ' lq . ... 1d' h �! ,,�� fi ��xr "'-. •'a7. .#, tA"s; It 1' .11 z a ''.-;',"%:;;;;: c::::'.1,..;:,4:::.; , S3 ; � : +� ', rn v a 7 x v � s-t t � a peg v�.; Sui `s s�l�4��,k urt�L� 2 _.,xe+xmsl ed?` "_ I fc,�xz x,,`i'�ti.. .+J , .,. �a F,-. ........ .. ......... n,3 A��s3aa 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 of condition is rated"severe", O O 0 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ 0 0 0 0 0 0 Eating Problems ❑ ❑ 0 0 0 0 0 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'/2 ❑ 2 ❑ 2% ❑ 3 ❑ 3% 6 Weld County SS-23A Addendu (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE Age 0-10...$16.32 - s4 ($496) . Basic Maint $4.93 day/$150mo Level 0 $0 County '-,. Age 11-14...$18.05 Therapy not needed or provided Basic , . ($549) No crisis intervention,Minimal CPA by Level 0...$0 Maint. Age 15-21...$19.27 (None) ($586) involvement,one face-to-face visit :i. another source,i.e.mental health. • +$.66 Respite Care `' ($20) with child per month. $19.73 . Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo S ,• 1 +$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy, T' ' one face-to-face visit per •' Lmonth with Level 1 ...$2.99 ($20.39 day/$620 mo) child, up to 4 hours/month. "' 2-3 contacts per month $23.01 1 1/2 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo --------- ------ - ($23.67 day/$720 mo) $26.30 Level 2 $11.51 day/$350 mo = Level 2 $9.86/$300 mo 2 . +$.66 Respite Care Occasional crisis intervention as needed, ,.?r Weekly scheduled therapy, Level 2..$4.47 s'F ($26.96 day/$820 mo) two face-to-face visits with child, 5-8 hours a month with 4 hours of ' k 2-3 contacts per month F 7 group therapy. $29.59 '2, 2 112 ,.; +$.66 Respite Care ;a Level 2 1/2 $13.15 day/$400 mo --.: -------------------- -------- 4, ($30.25 day/$920 mo) ..i t+)`- $32.88 '' Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo ' +$.66 Respite Care . Ongoing crisis intervention as needed, Regularly scheduled weekly multiple sessions,can include • 3 4 weekly face-to-face visits with child, more Level 3..$6.02 t d ($33.54day/$1020 mo) and intensive coordination of ,16 than 1 person, i.e.family therapy, Olemultiple services. for 9-12 hours/monthly. 7•74; ^5_.. $36.16 :1,:.',,:t ^; .' 31/2 l +$.66 Respite Care z Level 3 1/2 $16.44 day/$500 mo ','' ----------------- ------ r, ($36.82 day/$1,120 mo) , 3 .'a. $39.45 a'. Level 4 $18.08 day/$550 mo art,,; Level 4 $14.79/$450 mo +$.66 Respite Care Ongoing crisis intervention as needed, M°a` Regularly scheduled weekly ,',.:.;•: multiple sessions,can include 4 which includes high level of case TRCCF �' 9 er more • - Leve14....Neg. Drop Down management and CPA involvement with . than 1 person,i.e.family therapy, ($40.11 day/$1220 mo) ., : l child and provider and 2-3 face-to-face .aa•'• for 9-12 hours/monthly. contacts •er week minimum. . Assess/ rw < a 4,:.?, . Emergency $30.25 day/$920 mo •'' � , Y :.. $13.15 day/$400 mo a` � ----- '-------- -------- Level (Includes Respite) #. Rate Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendun 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 't le to OF THE WELD COUNTY 0: DEPARTMENT OF HUMAN 1161te5V1/49 ISERVICES ";iiiiii By. 149C Deput lerk to the Boar 7 Chair i nature Approval as to Substance: CONTRACTOR SEP 2 9 200 WELD COUNTY DEPARTMENT Adoption Alliance OF HUMAN SERVICES 2121 S. Oneda St, Suite 420 Denver, CO 80224 By: By: Di> ctor o?O/C-&.3OO 8 Weld County SS-23A Addendum • WELD COUNTY ADDENDUM • r • To that certain Agreement to Purchase Child Placement Agency Services /> (the "Agreement") between Ariel Child Placement Agency and Weld County `r£'� Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this /7 day of cep-leaks 2010, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the CPA identified as Provider ID#90205. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. County and Contractor agree that for Children's Habilitation Residential Program (CHRP) waiver eligible children, the County agrees to pay the federal SSI rate to Contractor and all other service costs will be billable under the CHRP program. 4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 5. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with family members, medical/dental or mental health appointments, extracurricular activities, court hearings or other specialized programming. Transportation expectations will be documented on the Child Specific Addendum, SS23B. 6. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 7. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays,the Contractor ore a3OC j Weld County SS-23A Addendum will contact the Emergency Duty Worker at the pager number (970) 304-2749. r 9. . Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel ' available for staffing current placements with the Service Utilization Unit. Contractor shall be notified by County staff of the date and time of the review. 10. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 11. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Contractor. All documentation of these examinations shall be forward to the County. 12. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student every 3 years and coordinate reviews every year. If the IEP is due while the child is in placement, the Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to the County. 13. Add Paragraph 18 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 14. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 15. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 2 Weld County SS-23A Addendum lb. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 18. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term"litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 19. Add Section VII-EXHIBITS: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS • NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S,NAME STATE ID# IEX F f1'RAILS CASE ID jDOB I WORKER COMPLETING ASSESSMENT �IHtJ I DATE OF ASSESSMENT I AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week 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 O31/2)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required 01)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 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 ❑I)Less than a ''/2 hour per day 01%) 1/2 hour a day ❑2) 1 hour a day O2 %) 1'/2-2 hours per day O3)2'/2-3 hours per day O3%)More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed DI)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 0 3)Constant basis during awake hours O3%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) I I to 15 hours per week ❑3) 16 to 20 per week O3%)21 or more hours per week A 1. How often is CPA/County case management required?(Does not include therapy) DBasic 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 4 Weld County SS-23A Addendur • (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. f ��tr >a a %a a. n—x nt, -•r x:r: .a „i t .x •t • , • :. ✓ '�s ikr: r M1 . S a ,4 .' " a`� ..,,k,.:„,.....?-,w k e,!.. ..,,,,,:-... t t I '7° S tSt ,:: —:4'...411 _ i '•M 4t " ST ti. .- 'iyi +. .t t, FT5 J t,tyl' t.2.11,? SS va*ar^ V _ii:la tics -4}4.'`.-;'u Al a' .k^.s%°• t?'; �'^Af t. t • ++t Aggression/Cruelty to Animals 0 ❑ ❑ 0 0 ❑ 0 Verbal or Physical Threatening 0 ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 ❑ ❑ 0 0 0 Stealing ❑ 0 ❑ 0 0 0 0 Self-injurious Behavior ❑ ❑ 0 ❑ 0 0 0 Substance Abuse ❑ 0 ❑ El 0 0 0 Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 El ❑ 0 0 Enuresis/Encopresis ❑ 0 ❑ 0 0 0 ❑ Runaway ❑ ❑ 0 0 0 0 0 Sexual Offenses ❑ 0 0 0 ❑ 0 0 5 Weld County SS-23A Addendum (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. t" ti'F WFll-; 4}i ,*ate a t: si x • r-* } ' 1.�' 3'� X 'S•+`a a^�w3i°s >v�.P: i i ° x Jtt,'. a5 t f :iy� .1"" s r dr , ,. 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 0 ❑ please complete the Medically fragile NBC) Emancipation O 0 0 0 ❑ 0 0 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family 0 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1% ❑ 2 ❑ 2%z ❑ 3 ❑ 3% 6 Weld County SS-23A Addendu • • (Exhibit C) • WELD COUNTY DEPARTMENT OF HUMAN SERVICES • NEEDS BASED CARE RATE TABLE "` '" Y t a.. l A` y Y 4 i 4 . z a Y 121•p r k 4-1,-;:',,:-4- v t P ¼. !ath --)1!“.<b yb . 'S 4 i 'Lr »• a` t r xz a F 4.,‘,..,44;,4,4. -hs ':;.';,t,',",::414,4, 1,'.1.:.::.5 .sa e:7'a Rsu z.....TM.�,r;K' + t`�.. m...,sth r} t r 4 Age 0-10...$16.32 r- ».e. s .. . iae: #a"5.+` 749 ($496) - Basic Maint $4.93 day/$15omo Level 0 $0 :::;:f County • Age 11-14...$18.05 ` Therapy not needed or provided -.::,g Basic ($549) No crisis intervention, Minimal CPA a . by Level 0...$0 Age 15-21...$19.27 a Maint. . (None) ($586) " involvement,one face-to-face visit . another source,i.e.mental health. '` ftb +$.66 Respite Care r;' A,. ($20) fit* with child per month. $19.73 V Level 1 $8.22 day/$250 mo -- Level 1 $4.93/$150 mo 1 +$.66 Respite Care Minimal crisis intervention as needed, *c,y Regularly scheduled therapy, one face-to-face visit per month with `. 1 .: Level 1 ...$2.99 ($20.39 day/$620 mo) pil child, k up to 4 hours/month. 4 -v', 2-3 contacts per month %,,,-.) $23.01 ra a `- '- 1 1/2 '°. ' +$.66 Respite Care II-41 Level 1 1/2 $9.86 day/$300 mo l..it ai ----------------- cap x - -------- ($23.67 day/$720 mo) iiit Lt $26.30 :9 Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo vs 3 2 +$.66 Respite Care 1,0 iii!" ipsoipso zfit Occasional crisis intervention as needed Weekly scheduled therapy Level 2..$4.47 ($26.96 day/$820 ma) o- two face-to-face visits with child, 5-8 hours a month with 4 hours of "r 2-3 contacts per month 7,..".,',:„;,': group therapy. $29.59 5 ;"*? 21/2 d +$_66 Respite Care . Level 2 1/2 $13.15 day/$400 mo -------------- `?tip ($30.25 day/$920 mo) . ,Pil $32.88 Level 3 $14.79 day/$450 mo aj Level 3 $14.79/$450 mo +$.66 Respite Care fl Ongoing crisis intervention as needed, f. Regularly scheduled weekly sip 3 iy'' multiple sessions,can include � v weekly face-to-face visits with child, more `. 3 Level 3..$6.02 • 1≥ ($33.54day/$1020 mo) 1 i 'a i7 �±,' and intensive coordination of 7 than 1 person,i.e.family therapy, ,.,,f:% z gin multiple services. ;. : for 9-12 hours/monthly. •i.'' $36.16 3 1/2 +$.66 Respite Care N A Level 3 1/2... $16.44 day/$500 mo 4i1; x4 r ------- ) Ora ($36.82 day/$1,120 mo) , $39.45 Level 4 $18.08 day/$550 mo t 4 44 Level 4 $14.79/$450 mo I in Iffl :,), },, +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly r.r': 4 i; ) a multiple sessions,can include :): TRCCF 14 which includes high level of case more •* Level 4....Neg. Drop Down to management and CPA involvement with 11 than 1person, i.e.family therapy, ! ($40.11 day/$1220 mo) 9 �.�, ,,, child and provider and 2-3 face-to-face for 9-12 hours/monthly.45 is ii.'My_ z, contacts .er week minimum :�':, 1 . ASSESS/ law MS " VI ligilEmergency $30.25 day/$920 mo S k q Level x,.ij (Includes Respite) $13.15 day/$400 mo i'lR ---------- -- '5K _---__- Rate *' tau Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, , month, and year first above written. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF Qw SOCIAL SERVICES, ON BEHALF \e(L,®` OF THE WELD COUNTY y f DEPARTMENT OF HUMAN �, SERVICES r‘ si4 BY: L11 � _A 1 0 0 � , aar) K`�� 1dd[fifl J� Deput lerk to the Boar T3/44. Chair Signature S�EP292010 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Ariel Child Placement Agency OF HUMAN SERVICES 4251 Kipling St, Unit 500 Wheat Ridge, CO 80033-2899 opootaiket- By: By: S[-3 irecto 0200-ate 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Commonworks D.B.A. Synthesis and Weld County Department of Human Services for the period from July 1, 2010 through June 30, 2011. The following provisions, made this )7day of 2010, are added to the referenced Agreement. Except as modified hereby, all terms of t e Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the CPA identified as Provider ID#104085. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. County and Contractor agree that for Children's Habilitation Residential Program (CHRP) waiver eligible children, the County agrees to pay the federal SSI rate to Contractor and all other service costs will be billable under the CHRP program. 4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 5. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with family members, medical/dental or mental health appointments, extracurricular activities, court hearings or other specialized programming. Transportation expectations will be documented on the Child Specific Addendum, SS23B. 6. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 7. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor aowo-a.36 Weld County SS-23A Addendum will contact the Emergency Duty Worker at the pager number(970) 304-2749. 9. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Service Utilization Unit. Contractor shall be notified by County staff of the date and time of the review. 10. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 11. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Contractor. All documentation of these examinations shall be forward to the County. 12. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student every 3 years and coordinate reviews every year. If the IEP is due while the child is in placement, the Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to the County. 13. Add Paragraph 18 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 14. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 15. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 2 Weld County SS-23A Addendum 16. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 18. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term"litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 19. Add Section VII-EXHIBITS: 3 Weld County SS-23A Addendum (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# 4EX F 'TRAILS CASE ID IDOB WORKER COMPLETING ASSESSMENT �1H# I DATE OF ASSESSMENT I AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1/)2 round trips a week ❑2)3-4 round trips a week. ❑2/)5 round trips a week O3)6 round trips a week O3%)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month ❑1'/:)Two times month O2)Three times a month O2%)Once a week O3)Two times a week O3%)Three times a week or more P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.)No educational requirements 01)Less than a '/,hour per day 01%)%hour a day ❑2) I hour a day O2 '/) 1%-2 hours per day ❑3)2'/r3 hours per day O3%) More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'/s) 11 to 14 hours per week ❑3)Constant basis during awake hours O3%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond 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 ❑3Y:)21 or more hours per week A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. O11/2) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'h) 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 O2)4-8 hours per month O3)9-12 hours per month 4 Weld County SS-23A Addendum . (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE • BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions..,..7::::::;:::::- which create the need for services that a..1 to this child. 1: xxi.�xuf § . ., at v :may%, 'V.::: .i.—,•-27;.f r i „ „. v ti ,�t * w, §1-,s. _ 1 '. s . v4 tL ' '° T2-.444.7*, s``,a,..e .,; h.. C.:�= aS se.S'.....,w:w:mro, hu.,.:-..,•.,. .• .: . .. e .5 _:`u.r�'': Aggression/Cruelty to Animals ❑ 0 0 0 0 0 0 Verbal or Physical Threatening ❑ ❑ 0 ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing O 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ 0 ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ 0 0 0 0 Enuresis/Encopresis ❑ 0 0 0 0 0 0 Runaway ❑ ❑ ❑ 0 0 0 0 Sexual Offenses O 0 0 0 0 0 0 5 Weld County SS-23A Addendum • (Exhibit B) • WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..I to this child. a+�� E' fir p m t x r kdr - u, `{t -a� �Y� #� z '-'"'t�*y� xN~< "'^{ + .t P; " +a°�4'v 4�" . as . fl.: � '*"'y1�7.;" " A� a '�'^"', ' .4 ]R .,� ,{d F"{ .: r yr:: ,P... .t' ,tE: . nk 'tr _1.S.i .« ...-'.. d. . 4 _ }�' v' r y`4`,,4 u�"°m,g,..� '�x '':';;I:''..1:11:1:1:1,' '' w� ay. 'a t� 3,r 'a a` �§' ar• 3k ��&t�,i,*w , y$� w *,v ^a°ut ., ,..ae 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ 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 E 11/4 ❑ 2 ❑ 2%z Ill ❑ 3'/z 6 Weld County SS-23A Addendum (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE �3m ke��rr'd�T+yi°@�sq d'�F � f 3. 1• ₹ t .y. b T4 ..e ap4Lk t _ y 1;if",°W.sm bw['`x4„,•to V �.re€xsi„,:.._.+._ . ..°...,'",:!1'f.:.:;..„.."..;:-::::;:•',1,•:. ..•) va ..0 . r: • w...... . _. .,.. . a... •• : ..• . ,x« z Age 0-10...$16.32 ($496) Basic Maint $4.93 day/$150mo Level 0 $0 1 County Age 11-14...$18.05 „i . ' Therapy not needed or provided i Basic Y ($549) "1 No crisis intervention, Minimal CPA �` by s' Level 0...$0 �-, Age 15-21...$19.27 t`° (None) Maint. x 9 s ($586) involvement,one face-to-face visit "+.�,° another source, i.e.mental health. +$.66 Respite Care ,SL j ",„ii ($20) $ with child per month. NO `. ,414 ` $19.73 , Level 1 $8.22 day/$250 mo f ti Level 1 $4.93/$150 mo n 1 +$.66 Respite Care k.:';•41:4 Minimal crisis intervention as needed, m'''',4; Regularly scheduled therapy, . Level 1 ...$2.99 one face-to-face visit per month with ($20.39 day/$620 mo) "vir child, up to 4 hours/month. len . w 2-3 contacts per month l''„;; y„i. $23.01 , `: x.;- ` 1 1/2 .• +$,66 Respite Care p',". Level 1 1/2 $9.86 day/$300 moa ------------------- '_ •, ($23.67 day/$720 mo) ''' `*° $26.30 Level 2 $11.51 day/$350 mo avl Level 2 $9.86/$300 mo ti 2a+$.66 Respite Care r""' Occasional crisis intervention as needed, •'*,u Weekly scheduled therapy, * 7.f Level 2..$4.47 i‘;..;1 two face-to-face visits with child, z°.�'l 5-8 hours a month with 4 hours of , ($26.96 day/$820 mo) �F, :e I'M 2-3 contacts per month r. group therapy. La $29.59 2•F: 2 112 • +$.66 Respite Care �=°ai Level 2 1/2 $13.15 day/$400 mo ),� ----------------------- '! ... ($30.25 day/$920 mo) w`' x Asa ,{ `' $32.88 Level 3 $14.79 day/$450 mo L Level 3 $14.79/$450 mo '`s g1.et* all ': +$.66 Respite Care o Ongoing crisis intervention as needed, Regularly scheduled weekly .;.?1,!,. multiple sessions,can include 3 „r °a ;"h= Level 3..$6.02 weekly face-to-face visits with child, c. more f"�"• ($33.54day/$1020 mo) P mil ?,a�1 and intensive coordination of A than 1 person,i.e.family therapy, d i:' '; multiple services. %:;" for 9-12 hours/monthly. lina $36.16 sy a 31/2 % +$.66 Respite Care !,,s•-• Level 3 1/2.........$16.44 day/$500 mo ms ($36.82 day/$1,120 mo) --- ,, $39.45 , t Level 4 $18.08 day/$550 mo f Level 4 $14.79/$450 mo ''* ,4 +$.66 Respite Care Ongoing crisis intervention as needed, (m Regularly scheduled weekly 4 t'§.l rt r.;�r-B multiple sessions,can include ' TRCCF $^h which includes high level of case 5T�R more I•" ' Level 4....Neg. Drop Down Fx management and CPA involvement with 51::.•211 than 1 person,i.e.family therapy, ($40.11 day/$1220 mo) 1,;y� V� 1 child and provider and 2-3 face-to-face for 9-12 hours/monthly. '' el _, contacts per week minimum. „, _ li Assess! °` _. ,r Emergency .. $30.25 day/$920 mo S" `' $13.15 day/$400 mo $�x, ---------- + ------- Level .. (Includes Respite) ra, Rate - Admin.Overhead Rate: As of 7/01/01 $6.91 day/$210.00 month 7 Weld County SS-23A Addenc 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 �! 1 I /j`\ OF THE WELD COUNTY moo DEPARTMENT OF HUMAN t ��I t;�t_� I SERVICES '46V ftimis BY: ft-A S a t \. , By Depute lato the BoarN*. ✓ C air Signature SEP 2 9 2010 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Commonworks D.B.A. Synthesis OF HUMAN SERVICES 5310 Ward Road, Suite G-01 Arvada, CO 80002 Q_80002 f - By: BY: alien Dom. irector 1 ou asd� 8 Weld County SS-23A Ad endum WELD COUNTY ADDENDUM • To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Hope & Home and Weld County Dept �of Human Services for the period from July 1,2010 through June 30,2011. 44 /9 The following provisions, made this , day of J1/,1, , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of th�Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the CPA identified as Provider ID#29867. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with family members, medical/dental or mental health appointments, extracurricular activities, court hearings or other specialized programming. Transportation expectations will be documented on the Child Specific Addendum, SS23B. 5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 6. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 7. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 304-2749. ace- O% O 1 Weld County SS-23A Addendum • 8. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Service Utilization Unit. Contractor shall be notified by County staff of the date and time of the review. 9. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 10. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Contractor. All documentation of these examinations shall be forward to the County. 11. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized Educational Plan(IEP) for youth designated as a Special Education Student every 3 years and coordinate reviews every year. If the IEP is due while the child is in placement, the Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to the County. 12. Add Paragraph 18 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 13. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 14. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 2 Weld County SS-23A Addendum 15. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 16. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 17. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s)to the Human Services' Director. The term"litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 18. Add Section VII-EXHIBITS: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS • NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# IEX F 'TRAILS CASE ID IDOB I WORKER COMPLETING ASSESSMENT IIH# ATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS J 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 P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑l)Once a month 01%)Two times month ❑2)Three times a month O2%)Once a week O3)Two times a week ❑3%z)Three times a week or more P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? 0 Basic Maint.)No educational requirements ❑l)Less than a%x hour per day 01%)%hour a day ❑2) 1 hour a day O2 %1) 1'h-2 hours per day O3)2'/-3 hours per day O 3%)More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑I)Less than 5 hours per week ❑1%)5 to 7 hours per week ❑2)8 to 10 hours per week O2%) 11 to 14 hours per week ❑3)Constant basis during awake hours O3%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feeding, bathing,grooming,physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week O2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week O3%)21 or more hours per week 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. O 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. ❑3)Face-to-face contact weekly with child and occasional crisis intervention. O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County SS-23A Addendum (Exhibit B) • WELD COUNTY DHS • NEEDS BASED CARE BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child. rod{ 1 a Aggression/Cruelty to Animals ❑ 0 0 ❑ ❑ 0 0 Verbal or Physical Threatening ❑ 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ ❑ 0 0 0 0 0 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 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ ❑ ❑ 0 0 0 ❑ 5 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child. Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior ❑ 0 0 0 0 0 0 Delinquent Behavior ❑ ❑ ❑ ❑ 0 0 0 Depressive-like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated"severe", ❑ ❑ ❑ ❑ ❑ ❑ ❑ please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ 0 0 0 0 0 0 Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 ❑ PA ❑ 2 ❑ 272 ❑ 3 ❑ 3'72 6 Weld County SS-23A Addend (Exhibit C) WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE k. w ..,,,,,,,c„ ,q Age 0-10...$16.32 " ($496) r Basic Maint $4.93 day/$150mo . ; Level 0 $0 •`'' Age 11-14...$18.05 Therapy not needed or provided County 9 • Basic a ($549) No crisis intervention,Minimal CPA by Level 0...$0 Maint Age 15-21...$19.27 ' (None) " ($586) involvement,one face-to-face visit another source,i.e.mental health. . +$,66 Respite Care ;S ($20) with child per month. 4 'Y''.1), $19.73 G -., Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo +$.66 Respite Care "; Minimal crisis intervention as needed, Regularly scheduled therapy, 1 :: Level 1 ...$2.99 one face-to-face visit per month with „- ($20.39 day/$620 mo) e� child, .:: up to 4 hours/month. 2-3 contacts per month $23.01 1 1/2 .1!"...4 4.66 Respite Care Level 1 1/2 $9.86 day/$300 mo s^a' --------------------- -------- ($23.67 day/$720 mo) $26.30 _ Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo 2 4.66 Respite Care Occasional crisis intervention as needed Weekly scheduled therapy, .. Level 2..$4.47 two face-to-face visits with child, „ 5-8 hours a month with 4 hours of ($26.96 day/$820 mo) (°- 2-3 contacts per month `�.,' group therapy. `, w '' $29.59 . 2 1/2 ,y 4.66 Respite Care e Level 2 1/2.........$13.15 day/$400 mo r z ----- i --------- ($30.25 day/$920 mo) �i!. $32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo 44,!X 4.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly 3 ;E ,�. multiple sessions,can include Level 3..$6.02 1• weekly face-to-face visits with child, more '� a ($33.54day/$1020 mo) C and intensive coordination of ., than 1 person,i.e.family therapy, TA multi•le services. for 9-12 hours/monthl . •s $36.16 3 1/2 `', 4.66 Respite Care S. Level 3 1/2 $16.44 day/$500 mo ' --............------- ----- x ($36.82 day/$1,120 mo) °'k4 $39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo w*F _ tip; +$.66 Respite Care ' Ongoing crisis intervention as needed µa''I Regularly scheduled weekly 4 . . . multiple sessions,can include TRCCF ,4',! axe which includes high level of case more Level 4....Neg. Drop Down . management and CPA involvement with than 1 person,i.e.family therapy, 4. ($40.11 day/$1220 mo) child and provider and 2-3 face-to-face for 9-12 hours/monthly. contacts •er week minimum Assess/ z` m Emergency x f.. $30.25 day/$920 mo ' R $13.15 day/$400 mo ' ------ --------- Level % «e. (Includes Respite) e "` Rate '1t-'K "' Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum • IN WITNESS WHEREOF,the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to to ward WELD COUNTY BOARD OF E ♦ SOCIAL SERVICES, ON BEHALF ® OF THE WELD COUNTY DEPARTMENT OF HUMAN lw l( -Th.4O SERVICES By By:Depu .*Clerk to the Boos "'"'" l Chat ignature SEP 2 9 2010 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Hope & Home OF HUMAN SERVICES 4945 N 30th Street, Suite 300 Colorado Springs, CO 80919-3152 By: . By: : '/ �L ;LJ // CZ / Dir etor ( /122 i a Q ;-(C rii" r Hope & Home 4945 N. 30th St Colorado Springs,, CO 80919 cze—ot3A 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Imagine and Weld County DepartiSi tpf Human Services for the period from 6 27 July 1, 2010 through June 30,2011. /1:3, The following provisions, made this / day of ail , 2010, are added to the referenced Agreement. Except as modified hereby, all terms of the remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Exhibit B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children placed within the CPA identified as Provider ID#21369. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. County and Contractor agree that for Children's Habilitation Residential Program (CHRP)waiver eligible children, the County agrees to pay the federal SSI rate to Contractor and all other service costs will be billable under the CHRP program. 4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 5. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with family members, medical/dental or mental health appointments, extracurricular activities, court hearings or other specialized programming. Transportation expectations will be documented on the Child Specific Addendum, SS23B. 6. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 7. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests,plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays,the Contractor ≤b/O -a3&1 1 Weld County SS-23A Addendum will contact the Emergency Duty Worker at the pager number(970) 304-2749. 9. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Service Utilization Unit. Contractor shall be notified by County staff of the date and time of the review. 10. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 11. Add Paragraph 16 to Section IV. Have medical examinations completed within 14 days and dental examinations completed within 8 weeks of the child being placed with Contractor. All documentation of these examinations shall be forward to the County. 12. Add Paragraph 17 to Section IV. Arrange a full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student every 3 years and coordinate reviews every year. If the IEP is due while the child is in placement,the Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to the County. 13. Add Paragraph 18 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 14. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 15. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 2 Weld County SS-23A Addendum 16. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 17. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 18. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five(5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term"litigation"includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 19. Add Section VII—EXHIBITS: 3 Weld County SS-23A Addendum (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT IDENTIFYING INFORMATION CHILD'S NAME STATE ID# riEX F [TRAILS CASE ID DOB WORKER COMPLETING ASSESSMENT jHH# �,t DATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic Maint.)Less than one round trip a week 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 O3)6 round trips a week ❑3%)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑1)Once a month ❑1''/)Two times month O2)Three times a month O2%)Once a week O3)Two times a week ❑3%)Three times a week or more P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O Basic Maint.)No educational requirements ❑1)Less than a'/ hour per day ❑1%) '/2 hour a day O2) I hour a day O2 ''A) 1'/,-2 hours per day O3)2'/:-3 hours per day ❑3%)More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.)No special involvement needed ❑I) Less than 5 hours per week ❑1%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%:) 11 to 14 hours per week ❑3)Constant basis during awake hours ❑3%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedim, 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 O2) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%)21 or more hours per week A 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.) On 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? ❑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 4 Weld County SS-23A Addendu (Exhibit B) WELD COUNTY D1-IS NEEDS BASED CARE BEHAVIOR ASSESSMENT a Please rate the behavior/intensi of conditions which create the need for services that a.I1 to this child k4a' ''m. a'4�°t*'s's�i i@'?'" .�x^'$r ,�tynti r' *x ll i '*A}u ,f fil$— ' ," y °+ b t s: w` w x-..)- 5;�� lal , lll.)+W u# a{ r n s ',y ."; it v .`an§ * Y " 1 s. �, r 1 1 ; ' q, dad.�� t'lty N v' a z .g ns7F 1 .„,-..x,k _ll. tq...-r'`A 11.41:t."1- a. '''s +.za:i.,'s..dka>" x�'.�t'e a. 'ai'+.� Yi' P �r..,�. _u *„' a Aggression/Cruelty to Animals 0 ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 0 0 0 0 0 0 Destructive of Property/Fire Setting 0 0 0 0 0 0 0 Stealing ❑ 0 0 0 0 0 0 Self-injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ 0 0 0 0 0 0 • Enuresis/Encopresis ❑ ❑ 0 0 0 0 0 Runaway ❑ 0 0 0 0 0 0 Sexual Offenses ❑ ❑ 0 0 0 0 0 5 Weld County SS-23A Addend (Exhibit B) WELD COUNTY DHS NEEDS BASED CARE BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/mtensit of conditions which create the need for services that as s I to this child. �''s r-i * }¢ ,1 �; t 3,+° I` r �'4%""' �A a '`` § *yb,; -{` r.�a�.. s sa '7 a re=^am s1kh�a.a�.5r s tai tl s i '"x rs as r r t • 4' n r y3 t 5+, a� `� ) - t s •r:-. • ^s 14� y^��Y$�h h *t a ht, a3 0•;•:,:r x. .a st } � +r 4 Y { i. €:.Mk s.F, .rya'.4°S ......: x,.^..,Y .*5 i:'M (^" .tl�'`.`f�..k .....°.Fa:t.sv�.7,U'vt i.2itIZ5:: , ;: P,..M:,,n7;4:. . .„ Inappropriate Sexual Behavior 0 0 0 ❑ 0 ❑ 0 Disruptive Behavior ❑ ❑ 0 ❑ ❑ ❑ 0 Delinquent Behavior ❑ ❑ 0 0 0 0 ❑ Depressive-like Behavior 0 0 ❑ 0 0 0 ❑ Medical Needs (If condition is rated"severe', ❑ O 0 0 0 0 0 please complete the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ 0 ❑ 0 ❑ ❑ ❑ Boundary Issues ❑ 0 ❑ 0 0 ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ 0 0 ❑ 0 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 ❑I ❑ 1'/ ❑ 2 ❑ 21 ❑ 3 ❑ 3'i 6 Weld County SS-23A Addend, • • (Exhibit C) WELD COUNTY DEPARTMENT'OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE a • •4.fs , su '$e ° • : . �,}',4° pti Age 0-10...$16.32 '; . ..... - .. .. . _ ($496) 4iu51 Basic Maint $4.93 day/$150mo ' Level 0 $0 :� Count Age 11-14...$18.05 Therapy not needed or provided Basic ($549) h" No crisis intervention,Minimal CPA by Level 0...$0 Maint. L Age 15-21...$19.27 ill; (None) - ($586) y''*1 involvement, one face-to-face visit ley4, another source, i.e.mental health. ;�; +TS, $.66 Respite Care t' lfi ($20) ,-vi; with child per month. hvl2. '`1 $19.73 Level 1 $8.22 day/$250 mo r Level 1 $4.93/$150 mo e�Pi, i. +$.66 Respite Care 3U Minimal crisis intervention as needed, 7.0 Regularly scheduled therapy, `�, 1 -s one face-to-face visit per month with ;I'll s k Level 1 ...$2.99 cl,• ($20.39 day/$620 mo) child, d1 up to 4 hours/month. ' 2-3 contacts per month li $23.01 .yt ; 1 1/2 +$.66 Respite Care $; Level 1 1/2 $9.86 day/$300 mo ' ----------------ikl -- ($23.67 day/$720 ma) p a $26.30 ',be Level 2 $11.51 day/$350 mokg 0,E,iF ,,q;,:•., $26.30 Level 2 $9.86/$300 mo Ili +$.66 Respite Care Occasional crisis intervention as needed, r° ,; Weekly scheduled therapy, .4 2 r , Level 2..$4.47 CO ($26.96 day/$820 mo) two face-to-face visits with child, 2:: 5-8 hours a month with 4 hours of t° a 2-3 contacts per month $'s group therapy. qaz se $all29.59 {criA -,..;g1 t:, 2 1/2 +$.66 Respite Care <e Level 2 1/2 $13.15 day/$400 mo ($30.25 day/$920 mo) �( $32.88 14 cii Level 3 $14.79 day/$450 mo t Level 3 $14.79/$450 mo " Bee +$.66 Respite Care Ongoing crisis intervention as needed, •,,r Regularly scheduled weekly 44,44.4 *: rA!Vg" 0. x�', multiple sessions,can include 3 3 '+ :a Level 3..$6.02 '�4.,- weekly face-to-face visits with child, S , more t. rilllii '144.• ,� ($33.54day/$1020 mo) and intensive coordination of than 1 person, i.e.family therapy, , VA i,ik multiple services. ' 1 for 9-12 hours/monthly. .r " $36.16 e}i, 3 1/2 +$.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo `k.. `'$I.. -------- FM ($36.82 day/$1,120 ma) 6' " ! . ' ral cw mw a�, $39.45 vpf Level 4 $18.08 day/$550 mo ' Level 4 $14.79/$450 mo _ riiift it+$.66 Respite Care R} Ongoing crisis intervention as needed, ,24„�' Regularly scheduled weekly multiple sessions,can include 5 . TRCCF which includes high level of case , more 5 Level 4_..Neg. Drop Down management and CPA involvement with 44'; than 1 person,i.e.family therapy, ;An ($40.11 day/$1220 mo) nr gig ;VI child and provider and 2-3 face-to-face l y 4 for 9-12 hours/monthly. .! RS ,! __ contacts •er week minimum. Assess/ 'eel A4li Emergency - $30.25 day/$920 mo l ' Level � (Includes Respite) $13.15 day/$400 mo `." ,j --------- Rate '' az l Admin.Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OINI � IPEta �` OF THE WELD COUNTY N. DEPARTMENT OF HUMAN � ;� �1 SERVICES A I Ism 0 �wit By. i/v t:1. . " Atirc. . / By.. Deput lerk to the Boal► i� ( ' N Ch r Signature �"��-•'� SEP 2 9 2090 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Imagine OF HUMAN SERVICES 1400 Dixon Ave Lafayette, CO 80026 By: By: Di i ctor 090!O—a,3Dc S Weld County SS-23A Addendum Hello