HomeMy WebLinkAbout20102194 MEMORANDUM
f&C 'ipil6 DATE: September 16. 2010
lTO: Douglas Rademacher. Chair, Weld County Board of
I����i Commissioners 1
{C L 1V )
COLORADO FROM: Judy A. Griego, Director, Human ServiOIIs Dep ent U
RE: Weld County Addendum to Purchase Cl4Id 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. 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
I Adoption Options Group Home/Foster Home $16.32-$40.11
July 1, 2010 —June 30, 2011 Aurora, Colorado
2 Bethany Christian Services Group Home/Foster Home $16.32-540.11
July I, 2010—June 30, 2011 Colorado Springs, Colorado
3 Bridges, Inc. Group Home/Foster Home $16.32-540.11
July 1, 2010—June 30, 2011 Pueblo, Colorado
4 Hope Family Services Group Home/Foster Home $16.32-540.11
July I. 2010—June 30. 2011 Greeley. Colorado
5 Journeys Inc. Group Home/Foster Home 516.32-540.11
July 1, 2010—June 30, 2011 Pueblo, Colorado
6 Kids Crossing Group Home/Foster Home $16.32-540.11
July 1, 2010—June 30, 2011 Colorado Springs, Colorado
7 Lost and Found Inc. Group Home/Foster Home 516.32-5,40.11
July I. 2010— June 30. 201 1 Wheatridge, Colorado
8 Lutheran Family Services of Group Home/Foster Home 516.32-$40.1 1
Colorado Fort Collins, Colorado
July 1, 2010—June 30, 2011
9 Maple Star Colorado Group Home/Foster Home $16.32-540.11
July 1. 2010—June 30, 2011 Denver. Colorado
10 Savio House Group Home/Foster Home S16.32-540.11
July 1, 2010—June 30, 2011 Denier, Colorado
11 Smith Agency Inc. Group Home/Foster Home $16.32-$40.11
July L 2010—June 30, 2011 Centennial, Colorado
12 Special Kids Special Families Group Home/Foster Home 516.32-540.11
July I, 2010—June 30, 201 I Colorado Springs, Colorado
13 Youth Ventures of Colorado Group Home/Foster Home $16.32-540.11
July I. 2010—June 30, 2011 Colorado Springs. Colorado
/17,(Jij
I y ' have any questions, give me a call at extension 6510. J
�'F/CJ� �/tC4 -6 tutEL. ' I ,. /4W)���, ipcni/C"� 2010-2194
•
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Servicd/g
(the "Agreement") between Adoption Options and Weld County Department* /
of Human Services for the period from 9
July 1, 2010 through June 30,2011. 435,
•
The following provisions, made this I t day of , 2010, are added to the referenced
Agreement. Except as modified hereby, all terms o 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#45078. 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 TRAILS CASE ID (DOB
M F If
I
WORKER COMPLETING ASSESSMENT rH# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I 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. O2%)5 round trips a week O3)6 round trips a week
❑3'/:)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month ❑1%)Two times month
O2)Three times a month ❑2%)Once a week O3)Two times a week
O3%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular 01
special education plan?
❑ Basic Maint.)No educational requirements 01) Less than a'/s 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
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%) II 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 feedin
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
❑2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week
O3'A)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.)
O 1) Face-to-face contact one time per month with child and minimal crisis intervention.
O 1%) Face-to-face contact one time per month with child and occasional crisis intervention.
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'/O Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addend
• (Exhibit B)
' • WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child.
E t * 4
ge g N4z r:t t
g k�. 14-e '� +, t xt a§ 1e 5 t '-'5::::i117,*:..
':.x ...,"�* a...��'.r.51v1-'7•71•4:4747•367k-�,z:,.,�.a��s..c 2i. ..:�s....��..�.s:'.,.r."�'rt.��w,'a A�'� w.,.,. - • . •. . -, "- 1
Aggression/Cruelty to
Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑
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
Substance Abuse
❑ 0 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 0 0 0 0
Enuresis/Encopresis
❑ ❑ ❑ ❑ 0 0 0
Runaway
❑ ❑ 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/intensi of conditions which create the need for services that a..1 to this child.
,G, .p k, S a i r 7:,T t r r�� a
` ,+x, y k 't yp . „ tap .�* u
:14,tu ` ,44441:r " ' st ate' i. *. . ; '' f r p..
x,='.l*.5,.... x`+€; ..w.xfi.aa t 2x:t. ;°`.ti_ N,..rx.%:.a„3...,6L*. .. • ..
M' .4y 2) 4, . b�
a }rpy1 ,p s, t1:4 w' k
iter.�altik sawn as .. 4. . ' c�'. ..,,7:-A„nth:n.44,s.✓r*024"1: . ..,. ...... . _. . _. .. y ., . . . . ...t ..a, ...;n.:
Inappropriate Sexual
Behavior El 0 ❑ 0 0 0 0
Disruptive Behavior
❑ ❑ ❑ ❑ 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 0 El 0 0
please complete the Medically
fragile NBC)
Emancipation
❑ 0 0 0 0 0 0
Eating Problems
❑ ❑ 0 0 ❑ ❑ ❑
Boundary Issues
❑ ❑ 0 0 ❑ 0 Cl
Requires Night Care
El 0 0 0 ❑ 0 0
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
Involvement with Child's
Family ❑ El ❑ El ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'% ❑ 2 ❑ 2'% ❑ 3 ❑ 3'%
6 Weld County SS-23A Addenc
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE PiciiitMti14x,95 a. u1}yy 1 1 • • T • • • '4yp
i‘;1,:!4;,:;..., . ;!1!''1 E.•cir'-.4:i L'i. $ij�V3 !, ,y'.. .3 c,i.-,,saw r� ,,.-1 tS : -x s a e ! 1� ' *z
':i4? it vii '$e: 7 a x.�"4 5 i ,; ,$ ..1: m;
" .a_.*,�.,3 x#..a*a:.m:'s9 's� rusrs�a€xx ......x<+,,i..:!;17,•,:1,, •: ;'....,:l: .x, . ._, , .. .. ... .. • • ,. .....e.. .k b,t
Age 0-10...$16.32 "s'"' V
($496) Pitl Basic Maint $4.93 day/$150mo -; Level 0 $0 �
Age 11-14...$18.05 Therapy not needed or provided
County
• ($549) No crisis intervention,Minimal CPA ;fix by :„.„.5
, Level 0...$0
Maint. Age 15-21...$19.27 ` ey , 'i (None)
($586) involvement,one face-to-face visit any another source,i.e.mental health. 'i°
44
+$.66 Respite Care .�;�
044 ($20) with child per month .
.''+ $19.73 °q Level 1.. $8.22 day/$250 mo ` " Level 1 $4.93/$150 mo �r
. t;
Sit +$.66 Respite Care Minimal crisis intervention as needed Regularly scheduled therapy,
1 '� l Lev el1 ...$2.99
s'' one face-to-face visit per month with
iffn ($20.39 day/$620 mo) rio child, up to 4 hours/month ^.
d. 2-3 contacts per month ' „5 P:
$23.01
"'
1 1/2 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo ------------------- --------
V1 ($23.67 day/$720 mo) .;,;v
iil $26.30 ite U.1* Level 2 $11.51 day/$350 mo : Level 2 $9.86/$300 mo ifA p
2 l +$,66 Respite Care mIX
PLis Occasional crisis intervention as needed, v'l Weekly scheduled therapy, ,
txttli ��"' y Level 2..$4.47
it
Ib., ($26.96 day/$820 mo) two face-to-face visits with child f` r 5-8 hours a month with 4 hours of , a
: . 2-3 contacts per month s group therapy. }a
1G
4' $29.59 N a g.. y
21/2 1 ' +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo ----------------------- ' ______'
day/$920 mo) vii,'
Shi )O1
Y
$32.88 1St Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, s 5': Regularly scheduled weekly '
Kti multiple sessions,can include a
3 i Level 3..$6.02
weekly face-to-face visits with child, ;{ more
($33.54day/$1020 mo) r and intensive coordination of )+ than 1 person,i.e.family therapy, w
a
multiple services. »; for 9-12 hours/monthly.
xa.
$36.16 ti ':,)",A!
3 1/2 +$.66 Respite Care '! Level 3 1/2 $16.44 day/$500 mo x ! �, ---------
($36.82 day/$1,120 mo) X,,II
+b, Alt ems..,. rr
$39.45 Level 4 PA $18.08 day/$550 mo Level 4 $14.79/$450 mo :.
a
+$.66 Respite Care '(a Ongoing crisis intervention as needed,tztate' Regularly scheduled weekly r
4 e;,
multiple sessions,can include
TRCCF which includes high level of case more t Level 4....Neg.
Drop Down management and CPA involvement with * than 1 person, i.e.family therapy, '
($40.11 day/$1220 mo) s a
(� child and provider and 2-3 face-to-face r)4:11for 9-12 hours/monthly. ,
AM ri ,,
;1 contacts .er week minimum .'FPI
VP Assess/ aq
Emergency ". $30.25 day/$920 mo E
to
$13.15 day/$400 mo (� ---------------- ----- -[
Level 5 (Includes Respite)
Rate °h il �4�1;'
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7
Weld County SS-23A Addendurt
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
f° ¢j OF THE WELD COUNTY
J/ a+y DEPARTMENT OF HUMAN
= SERVICES
tact ,•
iFirs
By �.�'r%/iLi � ►a `.%i: :<�' Imo: Vii Bye Q 4 r
Depu4'Clerk to the Bo.!'...�s / it-taxi/104'e
�ure
SEP 2 0 2010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Adoption Options
OF HUMAN SERVICES 13900 E Harvard Ave, Suite 200
Aurora,e CO 80014 l/1 By: By: un
irector M Ctiv
C le-> - /9 (/
8 Weld County SS-23A Addendum
• WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Bethany Christian Services and 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.
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#45514. 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 IDN SEX F I ID
OB
CASE ID DOB
IHH
WORKER COMPLETING ASSESSMENT N IDATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week 01)One round trip a week ❑1'/z)2 round trips a week
❑2)3-4 round trips a week. ❑2'/z)5 round trips a week 03)6 round trips a week
❑3'/z)7 round trips or more
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
❑2)Three times a month ❑2%z)Once a week 03)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?
❑ Basic Maint.)No educational requirements DI)Less than a ''/z hour per day ❑1%)'/z hour a day
❑2) 1 hour a day 02 %z) 1'/z-2 hours per day 03)2'/2-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1'%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2''/) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming, physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑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
03%)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.
(Le.mutual care placements.)
01)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.
❑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) DI)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/mtensit of conditions which create the need for services that a..1 to this child.
'" #'is a?t,�•a:`` y. ,q a .�+ iT: a^ wr rye:, t+# ti �, a
`a t i :' ro ^�; �z h4 :: a �,3w ri4 ..a#?.,1'i''yv `,iS , ' i _ it t
"' 'a t� i i,,,�r +�as xt 3Yav ' �" T i'
'" �w'��',a�,r" ,,k��( �'* `r a'` �`# tN•p,.�i`y '-s °w� r x �, • 'pu4�a
r ro �( �¢° ,$ra 4�y' � r '.
�''�
'. y ^8 §C+ .} du 1a.p. 44kw.{z. :,,E.5„ ` .t Sf ₹ dl p k P y..: yry }s4 'ir1L'
.,�'':. ..+ 6 •".s .'{'.. .�Pa;i43:_::vuTtit''2. i:.v:�....v.v .6 :.,,ah: Y .....'1t,i _. ..°t'. g
__. .. fd . ...e« .e.n '�Lx.n..edu'�'+di c.ex3P-
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
Enuresis/Encopresis
❑ ❑ 0 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/intensit of conditions which create the need for services that a..I to this child.%c "'={1 ? " ..c7: x+tra ad v < s � r 7:,,,I,:.;
3ro'
IL amp �y w„ dcw 'i1:4 3.� Y.L. t ,'
'+ wg 'i4;;V:A F x r d t xR" R at t r
P i. ��? 55"#+, ,}* �2w,%� +• 1r,� ,z ,,d� �- -+`. ,fir Ax.4i� '*�yt: +.liiiii Inappropriate Sexual
Behavior 0 0 0 0 ❑ 0 0
Disruptive Behavior
❑ ❑ ❑ 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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ 0 0 ❑
Boundary Issues
❑ ❑ 0 0 0 0 ❑
Requires Night Care
O 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 ❑ 11/2 ❑ 2 ❑ 2% ❑ 3 ❑ 3'h
6 Weld County SS-23A Addendum
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
N.:Ci� '" '^ ilt�'-" r i{ v?•
� r
i a
xx t
�i sw'° k>�a d,'u .,.+'.aa a..:,..3.� .. ...::".L.: � .P` r: � - ,teakieja .
e Age 0-10...$16.32 a v
itl laSk ($496) 4,4e, Basic Maint $4.93 day/$150mo ': Level 0 $0 +
in Age 11-14...$18.05 a: Therapy not '
County I ,,,',„2„:„,,,,:', needed or provided ._
Basic ($549) No crisis intervention, Minimal CPA by Level 0...$0
Mamt Age 15-21...$19.27 . .1 z (None)
($586) 'a involvement,one face-to-face visit *1'` = another source, i.e.mental health. p'';!
ptI +$,66 Respite Care U. C
%it.. ($20) with child per month. :` °""^
far fr.,4r
$19.73 7 Level 1 $8.22 day/$250 mo '7,1,i ,:: Level 1 $4.93/$150 mo ;
1 +$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy, *�
kid Am one face-to-face visit per month with ilifiri s Level 1 ...$2.99
kkit ($20.39 day/$620 mo) child, up to 4 hours/month. tiiiri
._ S
N5ii
` '• 2-3 contacts per monthBB
aka $23.01 L'
1 1/2 a, +$.66 Respite Care /`.. Level 1 1/2 $9.86 day/$300 mo
rv°$ w
($23.67 day/$720 mo) . ` '
tir
$26.30 Level 2 iq $11.51 day/$350 mo .,, Level 2 $9.86/$300 mo
2 +$.66 Respite Care Occasional crisis intervention as needed, v3 Weekly scheduled therapy, ; Level 2..$4.47
($26.96 day/$820 ma) two face-to-face visits with child, l 5-8 hours a month with 4 hours of
2-3 contacts er month :I::
}'i group therapy.p gar
m. $29.59 KAI "t + y �,
2 1/2 ', +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo ------------- --- ---------
ow ($30.25 day/$920 mo)
Tit it,zi- ,
wa $32_kali .88 Level 3 $14.79 day/$450 mo ? Level 3 $14.79/$450 mo =
Ire
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly x ,
3Uri 2t''. multiple sessions,can include •
:•N,::: Level 3..$6.02
„ weekly face-to-face visits with child, t'( more ;
($33.54day/$1020 mo) `�r; "..y
and intensive coordination of #, than 1 person,i.e.family therapy, :
8. multiple services. il for 9-12 hours/monthly.
��. $36.16 l , .,:
3 112 0 +$.66 Respite Care0;4 Level 3 1/2... $16.44 day/$500 mofir ________ ------- ---------
($36.82day/$1,120 mo) . > isst
i
.44
$39.45 '' Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo a""
}Ph°. �
+$.66 Respite Care :;. Ongoing crisis intervention as needed, ii` Regularly scheduled weekly X...5!;
4 �'(' a multiple sessions,can include .,,:,,,,,•,,;i1,
TRCCF S- F' . which includes high level of case ,i13,1
more Level 4....Neg.
Drop Down 1. management and CPA involvement with than 1 person, i.e.family therapy, .
($40.11 day/$1220 mo) w�'P 4.t
child and provider and 2-3 face-to-face N for 9-12 hours/monthly.
[s L„,°_ contacts •er week minimum. ` ;;"
ir rt.
ril!1
Assess/
Emergency $30.25 day/$920 mo b 1P k'�„
Level (Includes Respite) $13.15 day/$400 mo Fcl«i
st
Rate
ot
;1
Pe
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
V, OF THE WELD COUNTY
,tia DEPARTMENT OF HUMAN
a"•'` 1•� SERVICES
itm ,BALs2y: �q, By cL
Deput clerk to the Boa Chair Chai re
SEP20ZUIU
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Bethany Christian Services
OF HUMAN SERVICES 4820 Rusina Rd, Suite C
Colorado Springs, CO 80907-8127
By,: B
"rector
aEi/o-a 1r
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Bridges Inc. and Weld County Department of
Human Services for the period from
July 1, 2010 through June 30, 2011.
The following provisions, made this /6-11-ay of( f w-y , 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#1980. 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
$. 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 TRAILS CASE ID DOB
M F I I
WORKER COMPLETING ASSESSMENT IFIH# IDATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week 01)One round trip a week ❑1%)2 round trips a week
O2)3-4 round trips a week. ❑2%z)5 round trips a week O3)6 round trips a week
❑3%n)7 round trips or more
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
O2)Three times a month ❑2%)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?
❑Basic Maint.)No educational requirements ❑1)Less than a''%hour per day 01%)1/2 hour a day
O2) 1 hour a day O2 %1) 1'/z-2 hours per day O3)2'/z-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?
0 Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1'%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
0 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) I I to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑l)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'%)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
4 Weld County SS-23A Addendum
- (Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
•
j9g Please rate the behavior/intensity of conditions which create the need for services that ai 1 to this child. e
qt Y..� I {:% �['.'6
#. ' s °^ ti
i * P a {[4:.- . t n ¢ -14...t..;.•• Nnj„
;;SP II.,i 1° '4'..:'.4* ' t% a 41.4.,--*-,
fin ....... #a+ ei$ `- s d " .�v 3 'a § 4:',.i.'-a;;;41","a 5 5s ,.*5 ca
:k i!. :a�$ 'w i 1:..44,57,„...,,. .. ".,t a p"v. C x a %
Pva ...; '"4� R
.,I '�„ a, s%-4...,:ti,.,,, ,s K'.<.. _ ..... .z� r^,�k 3�w§;�&ai y_u�'xa°a.3..... . . ,. ... .... .. ..51:?...:.;. o... . . . ....^_��.
Aggression/Cruelty to
Animals 0 0 0 0 0 0 0
Verbal or Physical
Threatening ❑ 0 0 ❑ ❑ ❑ ❑
Destructive of
Property/Fire Setting 0 0 0 0 0 0 0
Stealing
❑ 0 0 0 0 0 0
Self-injurious Behavior
❑ ❑ ❑ 0 0 0 0
Substance Abuse
❑ ❑ ❑ ❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 0 0 0 0
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ ❑
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/intensit of conditions which create the need for services that a.'I to this child.
:.i ,:f ,'*iii,. .: s R i: . 'z + , M1 I.t#} ..,,t ,t„''., s s k%t fit. 15 "::!: > y ,-i:...„‘_:.. r ,.
"Y ta5 ''7:-',.,,!!:=2Y.- s , .7.: -: kx aaak„ . ₹ �..
eta t : ' � rr;s+ -.x` s e .%3-43.F.:.1:',.<::...,;. .__ ",haA ita4.7:a,. ....!1,7;.<1.44i.-:;,::;..:4);,-,...f.,,,:,...1,...:p. i..,a a.;.i= ad '� f.:-i .ti.!,,i.. 5a.... . . ... . . . ........5,,�..
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
Medical Needs
(If condition is rated"severe", ❑ ❑ 0 ❑ El 0 0
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ 0 0 0 ❑ 0
Eating Problems
❑ ❑ 0 0 0 0 0
Boundary Issues
❑ ❑ 0 0 ❑ 0 ❑
Requires Night Care
❑ ❑ ❑ ❑ ❑ ❑ ❑
Education
❑ ❑ 0 0 0 0 0
Involvement with Child's
Family ❑ ❑ ❑ ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 172 ❑ 2 ❑ 2'h ❑ 3 ❑ 3%
6 Weld County SS-23A Addendum
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
F t ' x - I 4 I d -'11 g'Pi
" , , . .
$.g��
Age 0-10...$16.32
($496) 13 Basic Maint $4.93 day/$150mo v y Level 0 $0
County Age 11-14...$18.05 x� "�,�'' Therapy not needed or provided *t`
Basic' ($549) • No crisis intervention,Minimal CPA ; by a Level 0...$0
Age 15-21...$19.27 '.-. ' (None)
Mamt L'74 b. 'w
($586tti ) • involvement,one face-to-face visit '�i another source, i.e.mental health.
+$.66 Respite Care .°
($20) with child per month. '
Pril -r
NIS $19.73 `itil Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
1 Pit +$.66 Respite Care - Minimal crisis intervention as needed, ii 1} Regularly scheduled therapy, ,tom
y, r t one face-to-face visit per month with ; s.1 Level 1 ...$2.99
t;,11.4' ($20.39 day/$620 mo) y child, ` , up to 4 hours/mouth y
r
a 2-3 contacts per month at,";
$23.01 {4
1 112 +$.66 Respite Care V Level 1 1/2... $9.86 day/$300 mo _4t
„s} ($23.67 day/$720 mo) S?; till
iiiiM
$26.30 w'. Level 2 $11.51 day/$350 mo r .z Level 2 $9.86/$300 mo .k
2 47 +$.66 Respite Care til Occasional crisis intervention as needed, :::1;,' Weekly scheduled therapy,
" ,. a Level 2..$4.47
tPag ($26.96 day/$820 mo) a two face-to-face visits with child, 5-8 hours a month with 4 hours of a
iiitki
},e. 2-3 contacts per month . . group therapy
$29.59 y ,.a
2 1/2 .. +$,66 Respite Care IV Level 2 1/2 $13.15 day/$400 mo .w"
`
..d
($30.25 day/$920 mo)
$32.88 Ifiti
ItreZrtiti Level 3 $14.79 day/$450 mo {° Level 3 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, u Regularly scheduled weekly
multiple sessions,can include
3 5 w- Level 3..$6.02
' weekly face-to-face visits with child a:1 more
($33.54day/$1020 mo)
• Lib, and intensive coordination of than 1 person, i.e,family therapy, 1:i.,,i.ii...t..‘,..7,1,..,i,;;
"xamultiple services. fiird• for 9-12 hours/monthly.$36.1671 3 1/2 ; b +$.66 Respite Care141 Level 3 1/2 $16.44 day/$500 mo ----
Vs. ($36.82 day/$1,120 mo) ;, 1
$39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
li
+$4ii .66 Respite Care 0'• Ongoing crisis intervention as needed Regularly scheduled weekly
4
+," o-•;4 multiple sessions,can include z,5
TRCCF ' a' which includes high level of case v` more Level 4....Neg.
'a 3a.
Drop Down -' 1 management and CPA involvement with adz; than 1 person, i.e.family therapy, r
L ($40.11 day/$1220 mo) " _
gi r child and provider and 2-3 face-to-face z for 9-12 hours/monthly.ttig tt'j
t p". contacts •er week minimum ,
Assess/ i ). °_
Emergency $30.25 day/$920 mo a $13.15 day/$400 moMini ) q
Level ., ' (Includes Respite) a �`
Rate +"' -
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 :•- WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
tut It ' % DEPARTMENT OF HUMAN
4' �i SERVICES itav By: �� /di ., !�_ �.;� ' i B : r
Deput1Clerk to the Board'^� C air Signature
SEP 2 0 2010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Bridges Inc.
OF HUMAN SERVICES 1225 N Main Street, Suite 102
Pueblo, CO 81003
By: y: ��
it ctor
7//5"//O
o2(;/(2-07/9 '
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Hope Family Services and 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 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#42942. 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.
0?(/D- ,?/9
] Weld County 55-23A 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# r4EX F 'TRAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT �F1H# 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
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
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
031/2)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 ''/3 hour per day 01%) 1/2 hour a day
02) 1 hour a day 02 %) 11/2-2 hours per day 03)2'/:-3 hours per day
03%)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 02%) 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 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 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03) Face-to-face contact weekly with child and occasional crisis intervention.
❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑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/intensit of conditions which create the need for services that a.'I to this child.
ii Su. s t'= i-ii �
a :'3° '°i ;j;" s - v-,;.:1- r re;s s v ax
an r5s`�'a "* a: '-ter x r).,..;;:'---1;',..."1;;;.! z i .,
4?M �+. 'h4°u � 'S§ i ,+ G ,4;.:;;;;„‘; da .!'e vd yf 6.:11,T. 714:1':,, ys ust w :; r:"...c:4'.5-'
F ' 4:-.it:—. r ...,11'.4':'`
,r-1 ... r,.t 3� x1"'t. vI,.3"y :.a. ,.$s .�.fi.,." R'!�.i�....; -. -" -'.. ,w 4.
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
❑ ❑ ❑ ❑ ❑ ❑ ❑
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
❑ ❑ ❑ ❑ ❑ ❑ ❑
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..1 to this child.
b fl �r Tym"n�v '2172 yrvu4'd' $'2f' 1, f tr ig f v, t
s.*���' r'� �r s r 't s +" s� � to k �f ,.)�° r s k
lfilf„'t,€r, ''°ai§"r : t ni f2. '+'i fl:l l.. a'",.rw e fill' i d '� E } v. S:
:
:ry: h 9_ a Afi.,eptti a v,,r .:r � 'SF u ; E 'mot
?�4 v iG va �. H d.xg t -
'r
P ` "
.r::: q a .r A l n a y 9 x �.
* �` }^ g'v *'r``f fir ' }""^s gst Fd$xcy s ¢ s••:-..:,ry • . e ys .°r
° %y:':?:',4.x,� '",a�:.it #:' m : ' a� ,�x , ...kr as " ,. �, . � .. *" )
..-..2. 3,�ro+W,'�+.�T'a r�nit§,'la'Std€tIr'°'�+§'Y:.�a"�.utlYa,.a5 .. to@.6<$,.., a. , . . �tic:.�s§ *..:k...+.. . :..aab�..sd
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior
❑ 0 0 0 0 0 0
Depressive-like Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe", ❑ 0 0 0 0 0 0
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ ❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues
❑ 0 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 ❑ 11/2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 31/2
6 Weld County SS-23A Addendum
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
lax .:t.s `::: " ` '' . *.,, c;';,.:';',' ' t :s. a f . •,
t t 1i 3P. • kk T7A...i4k"Y .:*.:k 3 ...t.'3',',*
''x�?3 .�tu7 i 3 [ O'''...,,:,c� xt "t az0.
'LPk"Y i"T 5M 4 43 irni.s° 4 N :iri;§ A } M
li':';:aF
Mit Age 0-10...$16.32 pit +4 ''
($496) Basic Maint $4.93 day/$150mo Level 0 $0 `
1, Age 11-14...$18.05 2 a);, Therapy not needed or provided
County °' ,
Basic ($549) +;x No crisis intervention, Minimal CPA &'„Via by w� Level 0...$0
Maint. a Age 15-21...$19.27 i _ (None)
($586) �` § involvement,one face-to-face visit 41;: another source, i.e.mental health.
,f +$.66 Respite Care k
'c; ($20) rwl with child per month. r�- "*
F.MiqW $19.73 Level 1 $8.22 day/$250 mo °y' Level 1 $4.93/$150 mo aDta '"
• +$.66 Respite Care e, Minimal crisis intervention as needed Regularly scheduled therapy,
1 a one face-to-face visit per month with ,- ,_ .e Level 1 ...$2.99
zwe ($20.39 day/$620 mo) child, ���1, up to 4 hours/month. y.
'40 �L &,4 4 2-3 contacts per month ,FF *.H
$23.01 F
Ist1 1/2 +$.66 Respite Care :, Level 1 1/2 $9.86 day/$300 mo + ------------------ -- ---------
W ($23.67 day/$720 mo) ;, =x
At $26.30 NA Level 2 $11.51 day/$350 mo a, t Level 2 $9.86/$300 mo
s ,c
2 +$.66 Respite Care Occasional crisis intervention as needed Weekly scheduled therapy, k' Level 2..$4.47
tl two face-to-face visits with child, 5-8 hours a month with 4 hours of '..•&,;
s ($26.96 day/$820 mo) (k`1 ��_,
MI 2-3 contacts per month • group therapy.
;`
$29.59 2'' 4
2 1/2 I +$.66 Respite Care isle Level 2 1/2.........$13.15 day/$400 mo ------------- `s
($30.25 day/$920 mo)
$32.88 °*�� Level 3.. $14.79 day/$450 mo par Level 3 $14.79/$450 mo :.7.:4
+$.66 Respite Care Ongoing crisis intervention as needed, g:i Regularly scheduled weekly . k.°
StPi Lift multiple sessions,can include '',` Level 3..$6.02
3 weekly face-to-face visits with child, more
($33.54day/$1020 mo) 1 , a ? *�.
Wii
a. and intensive coordination of than 1 person, i.e.family therapy, ,s
AN51C1
e multiple services. for 9-12 hours/monthly. &IL
icax t, Ws `';
$36.16 'sI .I
3 1/2 rg, 4.66 Respite Care = Level 3 1/2 $16.44 day/$500 mo lqAl
til ($36.82 day/$1,120 mo) 1 !
M. $39.45 In Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo rii
iipli +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly ° ?
4 multiple sessions,can include w,'t'
TRCCF PS *kt"px..a which includes high level of case , more a* Level 4....Neg.
04 te.
Drop Down ,: management and CPA involvement with in than 1 person, i.e.family therapy,
• ($40.11 day/$1220 mo)
tit1 t',441
child and provider and 2-3 face-to-face re:4 for 9-12 hours/monthly.
„g contacts •er week minimum.
Assess/ 1
Emergency ..a $30.25 day/$920 mo $13.15 day/$400 mo - --- �yt`
Level Vit. (Includes Respite) ' 4T
Rate
Admin.Overhead Rate: As of 7/01/Of
$6.91 day/$210.00 month
7 Weld County SS-23A Addend
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF
�...� SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF HUMAN
SERVICES
�.$6, 1� �,�•�.. - tl
By: Ii« > _ ` � .; I B _
r1 tip ♦ y
Deputy clerk to the Bo.9p � Ch r Signature
SEP202010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Hope Family Services
OF HUMAN SERVICES 1610 29th Ave Place #100
Greeley, C
By. By
Di for
8 Weld County SS-23A Addendum
• • WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Journeys Inc. and 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.
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#1525317. 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 F !TRAILS CASE ID IDOB
WORKER COMPLETING ASSESSMENT 1HH# M I 1DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I 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'/z)2 round trips a week
❑2)3-4 round trips a week. ❑2'/z)5 round trips a week 03)6 round trips a week
❑3'/z)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑1)Once a month 011/2)Two times month
02)Three times a month ❑2''/)Once a week 03)Two times a week
❑3'/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?
❑ Basic Maint.)No educational requirements ❑1)Less than a'/z hour per day 01%) 1/2 hour a day
02) 1 hour a day 02 %) I'/z-2 hours per day 03)2'%-3 hours per day
❑3%z) More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed 01) Less than 5 hours per week ❑1%z)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
P 5. How much time is the provider required to assist the child because of impairments beyond}me 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
03%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
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) ❑1)Less than 4 hours per month
02)4-8 hours per month 03)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..! to this child.
¢ ° .:Isj ,v 'xu. `4"—. ,j.' 5 S 4 n }r *. :4'":'?:::::':.";:/.; tr' y zega
i -rg` ' mo t, sit.. r �, - '` t ".45b.,7
. b, :.
' „R.ar"s , > .'fi t } , y ,titer Uzi � ` y
..mv.thtiv+-x .- . 'i a.ir:te 3 ,. d ,,,i,2,7:4-7:7,;13,,N7 *i'A`i ,0ei.,;,„,141,:.,,' t ,,M.
- tr r . t34t. : 1' " tic ,` �, 614a: ; ;,-•a' r -,...‘.2.,'.',
. �1 .2 -. 'is ..sy. ks..,a.,r4....... . ,.aEd sw..i u. '4�,t Yl'4- :Au.x5 4sir.,:si....y .. . v .. . . ..e .. ra...a r,' {.
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
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 0
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
O 0 0 0 0 0 0
Sexual Offenses
❑ ❑ ❑ 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..l to this child.
ii:'�i,��t�3� *d swei/,':, .-� -i ma 1 ..!,11.1.i.-.-ft r......, j
a ,.:7,;.`.ill':' .,, . '. ,, Pic ..,' `�' t
4 4 s x t$, fal.'.: t fi .:. 4kks §.. a 3;;;',T , ,-e
�';°s . s - , rrys ;Ta'. xs ,;� ,,.2-1, '4V.I." ' c k' r'` °uri: yr;
fl, a ro ''','„2":\ € t s 'v.im'
u� t Y it
'%,.,d,�,d'.�,a :�4' 3.,.a,�, . r,F, a:-..'a, ,.. 3 t e *+^ s 1 ''
.�:S.��._ aae,.st'rti�,�„Y- �..,x.a'� n4,,.,.,c�� .. .>a"k'?tafinr+�"ni.�+.+. ws��.��'1�. ...=x:_ . •.._. ., ....
Inappropriate Sexual
Behavior 0 0 CI 0 0 0
Disruptive Behavior
❑ 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 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
❑ ❑ 0 0 ❑ 0 0
Education
❑ ❑ ❑ 0 ❑ ❑ ❑
Involvement with Child's
Family ❑ ❑ ❑ ❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1% ❑ 2 ❑ 21 El3 Ill 31/2
6 Weld County SS-23A Addendum
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
UPTEt.Y q� %27� S4`..'°§ '•okra `.4fix�"d v?x ° '3 r 4f., 4 . +.,,,
- o",.s.<. ., ....... . .. : .a . c :s`,'k.
ass Age 0-10...$16.32 ', T¢ .w
ire
($496) F Basic Maint $4.93 day/$150mo Level 0 $0 _
County r
Age 11-14...$18.05 n elitist Therapy not needed or provided
Basle ($549) k' No crisis intervention,Minimal CPA by Level 0...$0
Age 15-21...$19.27 t ' (None)
Maint. ., ($586) , involvement,one face-to-face visit '�, another source,i.e.mental health. .4i,",
rigptini +$.66 Respite Care 71.71 _' '
IN ($20) Lx with child per month. riral . :k;1
$19.73 a, Level 1 $8.22 day/$250 mo c Level 1 $4.93/$150 mo :.f..,-'.
sx
'b Y
OM +$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy, •
1Iiiiti
one face-to-face visit per month with a^- Level 1 ...$2.99
($20.39 day/$620 mo) child, ""'t up to 4 hours/month. , 4
F 2-3 contacts per month tit
$23.01 4: to `'''
1 1/2 +$.66 Respite Care 4" Level 1 1/2 $9.86 day/$300 mo ar''`1 ---------
($23.67 day/$720 mo) r..±1::,.
`� "� ;
n, r
$26.30 I""` Level 2 $11.51 day/$350 mo •t,'ry. Level 2 $9.86/$300 mo ,
+$.66 Respite Care Occasional crisis intervention as needed, ntif Weekly scheduled therapy,
2Level 2..$4.47
4 two face-to-face visits with child, a 5-8 hours a month with 4 hours of t „
41 ($26.96 day/$820 mo) if
& 2-3 contacts per month .. group therapy. .
Wif
1.14 $29.59Al
Sti •a:
21/2 ' +$.66 Respite Care Level 21/2 $13.15 day/$400 mo .r= ----------- ------- ---------
($30.25 day/$920 mo) a :41
Mg
$32.88 Level 3Ill .. $14.79 day/$450 mo Level 3 $14.79/$450 mo a
a +$,66 Respite Care ti.: Ongoing crisis intervention as needed ;{ Regularly scheduled weekly
Viii: multiple sessions,can include '
3 h # F Level 3..$6.02
weekly face-to-face visits with child, - more
4'41 ($33.54day/$1020 mo) °4F
5.474 and intensive coordination of .i than 1 person,i.e.family therapy, 4
,se't multiple services. .°' for 9-12 hours/monthly. a'a'_-`.
$36.16 »
3 1/2 +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo - --- ,,'
rk ($36.82 day/$1,120 mo) - ----- -------
$39ttzt
.45 `k Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo r*4ri
+$.66 Respite Care 27.g4.1 Ongoing crisis intervention as needed, ! Regularly scheduled weekly go
4 = ti multiple sessions,can include �,1
TRCCF which includes high level of case •. ' more Level 4....Neg.
'
Drop Down ti management and CPA involvement with than 1 person, i.e.family therapy, "'
($40.11 day/$1220 mo) h. '
!III.,;,,
tig ` ` child and provider and 2-3 face-to-face �', for 9-12 hours/monthly. .
contacts •er week minimum. '
4.:4 iara
419
Assess/ .a Viii s s
Emergency $30.25 day/$920 mo ?).,"7.
, .:. �+,
$13.15 day/$400 mo
Level (Includes Respite)
Rate t. s 'S
x
oim
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
OF THE WELD COUNTY• DEPARTMENT OF HUMAN
SERVICES
By: � By.
Depu t lerk to the Boa _�:ti.1 Ch i Signature
SEP 2 0 2010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Journeys Inc.
OF HUMAN SERVICES 503 N Main Street
Pueblo, CO 81003
By: By:
ector
076/ c7/99
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services it
(the "Agreement") between Lost and Found Inc. and Weld County
Department of Human Services for the period from
July 1,2010 through June 30,2011. / •
The following provisions, made this 9t day of .;iLL) , 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#57351. 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.
an/n— /9
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 'TRAILS CASE ID IDOB
M F I
WORKER COMPLETING ASSESSMENT r H# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I PROVIDER TRAILS I 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 ❑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
❑3'/z)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
02)Three times a month 02%)Once a week 03)Two times a week
❑3%n)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 ''/z hour per day ❑l'/)'%hour a day
02) 1 hour a day 02 %) 1'/-2 hours per day 03)2'/r3 hours per day
03%)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 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week 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
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.
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
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..ly to this child.
i'nx ". sN,-q=rc° .txm, a'
§v 2 .. r`�'+,'c ak r�` ttrp4 +'a. : Ptrs'wa+$ �. ' i:
4 "xa} 1 o-a'9 t it r n tt+.��„ P a�°rt �+�1%' x c� §:
~xw 'I ,r ri n.. .7 ° ":“.i '&w5:" v ,').. ;' C a
�. •* ten, ». ti '��' � ��p}a �J�€ r� �t �y `" � ; .
."'. ,P x. ?-.4,;,114-,........At'. de.5..va;x ..r, `dam..
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 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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ 0 0 0 0
Sexual Offenses
❑ ❑ ❑ ❑ ❑ 0 0
5 Weld County SS-23A Addendum
J (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.$1 to this child.
7/1115 2 'c ' v +, '°.x > ::; z +rvv 'sue a w .Y;g. apcs -, £ ,' .
�x ° t y,l a 1 y-;,41-4:,7f, r �'�. I .s t vi +�
_hv ..uyLv°_e .', r,.. tiCw„ ,1/2 ihp,.. ,,,W, v L" }:,y'
"° ::5;-.r x'}' ,,'t, "v r r',,41‘; I. : ,.:a ,a, st ail?
r '
' '' l,. is �`- t`�' .t≥5 '..„ ‘7.(., "U 5s ` n;,i,�7,;:..olski 35,44. • :,'?
.... .�. ,; ate+ c`.y, °'5. -,`�vaias .: ,..,, .` 'a>w.'4t % s °�
.. .'.'a? �##�,.#mss, �"'x§d ¥a..>.,x>a:':,,k a�i�m'`..t % *t . . . .., .e ... . ..... . ...�.,.�e... ....,e.x.";x,..$....�'�:
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ ❑ 0 0 0 ❑ 0
Delinquent Behavior
❑ ❑ ❑ ❑ 0 0 0
Depressive-like Behavior
O 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 0
Boundary Issues
❑ ❑ ❑ 0 ❑ 0 0
Requires Night Care
❑ 0 0 0 0 0 0
Education
O 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'/z ❑ 3 ❑ 3'/2
6 Weld County SS-23A Addendun
j ..
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
t° . '' `A ,m#'r"s `cv s ' ':, ,re vy :, A". 1 r 'a." 9
wt: x
aS ,E�.e' itil 'i 'w`i `1 £a is a re 'w„,Y. 3 , t,.: rte*p �.?� • • • ,
t•,f � � i t k r )3.14 .*z r4 I�£ } q +; 3 � r yr ms w ; a f
a Awe. .tlft is 't" 44,z,.a itili ra ',r n'^1^ 4 e % - i `s. - '5�s °` 4'h
ar� xis�3P'3 a :r. 4. 3 ;``),.t wo- ,tea4 '.•^E"a +a ryb .s* a 4 k4 a
`re +r.}',*' A'st, �t li"F �«1'" a! ii' r: 's + x '`'�, R 4, +fi'2';'..::::,4,:;;..-;':;.;:: ' t 5.4'
R V7i I t .;a`tnirt4.7*;', fen s'.} $. „ .iM 'f:. , k:.. ..-_ -.:. ......- a. ' :: ra„,ki.ity
�.
Age 0-10...$16.32 A:' �_- 4s �.. c
($496) #� Basic Maint $4.93 day/$150mo 4.. Level 0 $0 ,.
County inig Age 11-14...$18.05 r < Therapy not needed or provided 'za
Basic ($549) '- No crisis intervention, Minimal CPA Irv,by Level 0...$0
Maint. Age 15-21...$19.27 s.1+ (None)
($586) involvement,one face-to-face visit 1 another source,i.e.mental health.
eili
+$.66 Respite Care
($20) IMA with child per month.
ol
$19.73 Level 1 $8.22 day/$250 mo ro x AA.A Level 1 $4.93/$150 mo iiii
+$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy, '
1 Level 1 ...$2.99
one face-to-face visit per month with e, ':
($20.39 day/$620 mo) ") child, ,;' up to 4 hours/month. AAA
Si.;:.
2-3 contacts per month
$23.01Mt' se
1 1/2 +$.66 Respite Care AA.;‘, Level 1 1/2 $9.86 day/$300 mo ?pi -- -."
----------
($23.67 day/$720 mo) t°," . 1&kA,
$26.30 lAta Level 2.. $11.51 day/$350 mo Level 2 $9.86/$300 mo i
"bill
+$.66 Respite Care r-IAA, Occasional crisis intervention as needed Weekly scheduled therapy.
2 re : + Level 2..$4.47
e gr •
two face-to-face visits with child, 0 5-8 hours a month with 4 hours of �`
($26.96 day/$820 mo) irli
,
2-3 contacts per month group therapy.
NI
..
ES $29.59
2 1/2 tar +$.66 Respite Care pri Level 2 1/2.........$13.15 day/$400 mo --------------------- --------
($30.25 day/$920 mo) Eta Lim 64 C
Inv
31O1 $32.88 "C.11 Level 3 $14.79 day/$450 mo r`Alkai Level 3 $14.79/$450 mo IAA
itAk 774i AAA
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
AA 44:i
3 yriA multiple sessions,can include Level 3..$6.02
el Oil weekly face-to-face visits with child, more Ae
($33.54day/$1020 mo) ,..e.
i....
and intensive coordination of than 1 person, i.e.family therapy,
4
E multiple services. rils! 54
for 9-12 hours/monthly.
lig$36.16 4. `"''s
3 1/2 +$.66 Respite Care =: Level 3 1/2 $16.44 day/$500 mo raft:
m
($36.82 day/$1,120 mo) _ g 4
.
,itiki FAA
$39.45 Level 4 $18.08 day/$550 mo I' Level 4 $14.79/$450 mo {4
+$.66 Respite Care "'" Ongoing crisis intervention as needed, 1. Regularly scheduled weekly
4 z multiple sessions,can include =g
TRCCF which includes high level of case more , Level 4....Neg.
Drop Down ($40.11 day/$1220 mo) management and CPA involvement with ?• than 1 person,i.e.family therapy, t
figi
child and provider and 2-3 face-to-face for 9-12 hours/monthly. +
contacts .er week minimum. „ ,
Assess/
Emergency $30.25 day/$920 mo ML. $13.15 day/$400 mo
Level (Includes Respite) ry
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 t WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
7-5 tf ''� DEPARTMENT OF HUMAN
I��' ¶'%:u`. .111 SERVICES
Ohat
'•`�; '� ~ ' k' u(0010—
Deputy Il�i> .._� � , �� :' i%L -:� B cx� S �
Deputy i erk to the Board 7 Ch it Signature
SEP 2 0 2010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Lost and Found Inc.
OF HUMAN SERVICES 6700 44th Ave
Wheatridge, CO 80033
By: By:
Dir ctor
c9(/e- a 19
8 Weld County SS-23A Addendum
• •
• WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Sedeesifin
(the "Agreement") between Kids Crossing and Weld County Department 04 /6
Human Services for the period from 4ih
July 1, 2010 through June 30, 2011. <�
The following provisions, made this f day of , 2010, are added to the referenced
Agreement. Except as modified hereby, all terms o t 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#79752. 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.
at/ - °?l/
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# EX F RAILS CASE ID 0O6
WORKER COMPLETING ASSESSMENT HH# I DATE OF ASSESSMENT
I
AGENCY NAME PROVIDER NAME I 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
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 01%)Two times month
O2)Three times a month O2%)Once a week ❑3)Two times a week
O3%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1) Less than a''/x hour per day ❑1%) '/:hour a day
O2) 1 hour a day O2 %) 1'h-2 hours per day O3)2'h-3 hours per day
❑3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed DI)Less than 5 hours per week ❑1%)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 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 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
O3%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
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
4 Weld County SS-23A Addendum
• (Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that al II to this child.
�$"v�"s", " , n - ,G ,r ✓iH � T�t'� x t-+iT,xpr,r u s r �
'§%yvai1. '"ti p t r .(°d .. T ..TN. 4 , .r, MY .) E Sh
��S* �y <a f gam,� E.:4 t �� i1191.1.fRtirifitIlitroCZ4.-...st-7:-, r � °�.."7%<r 3�" a-''��+Sa r p
m. e.. ...- v�°.wrdv Rv 4amA%x!. i!M1 1�u S' if e ..a. ..L . ... .e..„ hi �ni vi.S..Mn .0 i.
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
O 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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ 0 0 0 0
Sexual Offenses
❑ ❑ 0 0 0 0 0
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..l to this child.
irte ` v`S}' " , ':' " Y . 'z"-'r9,4� Y,;33 itr.-,ras 4 ✓ t�'. +
`'r,`� .' i" 4' : yf gt w i k v r::,t.P.1;4�,1u' #vase
a. a r .. e
a"sd; _s�" _ x5...3%;:- v�.'`.:dx.e.t.... ,}e_�w. _.w.x.S`^.ha $* tl,.,,'#S.`x.51;.vt�Td&IC+"k§3..,s�" x�.ax_ �.
,,; �' °° ,wt �.�,‘( fit ° :s+ R.2, •.:Ap hier"tia.:0',;'�1';:'in� Mtw ....,,y' ` y r - "• : .,
�- __�. 7s�''e'°+o s..as. szvl,:3v._�..6....:i•:ice.wa5•,�a. . ., ,...,. . 4.... ......,„::-,,,i,..-''.- '�.:_..e .n mn.e, .x� .n'5X�
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ ❑ ❑ 0 0 0 0
Delinquent Behavior
❑ ❑ 0 0 0 0 0
Depressive-like Behavior
❑ 0 0 0 0 0 0
Medical Needs
(If condition is rated"severe", ❑ 0 0 0 0 0 0
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ ❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑ ❑ ❑ 0
Education
❑ ❑ 0 0 0 0 0
Involvement with Child's
Family 0 0 0 0 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 rill ❑ 11/2 ❑ 2 ❑ 21 ❑ 3 ❑ 31/2
6 Weld County SS-23A Addendum
•
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
trail +y,.,e;!..47,14:-.....2i.;.. ,tis '� t s.;,..Aft.
k't 'v: t . 9hv 2 . ;a : s c `° F 1 yr • • '£
ii l § p Y Al, a'�f #'s y.'v� i +' fr Alp .a.d f C` q i S!
•.431:1 frli'# " . 9 vt... k.T� sl a^ v, r2 *kc t y 1 ' sa r
�. � �`,na se=x c znx r�-' + av, .C+a �. '� .w n .i t'�, .
xi.&,,.. .:,
k1 m d a` " a # rAwi-Siks.t 7- a* * s k -,::::!,?,;V.;•?? rye b 'T.:.,4,;:,....,...: a:','
zn£ a'. ' s'_h "i"d'P.S:N`WE stkih"s;. �aroro.,,:ci.s..i.....i,:ui .,, ,, ,,a, ',,%..."& :ce. 2. ,,,,:a.,..,,,,,,,...„,
,$A`, . , ... . .. . ..w.. ., ,,,,.=.„. ..,.?e
iiiiii Age 0-10...$16.32 .
($496) Basic Maint $4.93 day/$150mo Level 0 $0 " :i
County Age 11-14...$18.05 Therapy not needed or provided '`,n�
Basic ($549) No crisis intervention,Minimal CPA ` by u Level 0...$0
Maint. set Age 15-21...$19.27 a a,,, :, (None)
($586) q involvement,one face-to-face visit , another source, i.e.mental health.
+$.66 Respite Care f1.
Fig,
, ($20) with child per month. ill,i " q
n21 ti : ai
$19.73 Level 1 $8.22 day/$250 mo 'tr, Level 1 $4.93/$150 mo a
4frip +$.66 Respite Care Minimal crisis intervention as needed :. Regularly scheduled therapy, ttfl Level 1 ...$2.99
'A one face-to-face visit per month with
child, up to 4 hours/month. �__°
_. ($20.39 day/$620 mo) o- ;
ifil2-3 contacts per month y,
$23.01 1,
1 1/2 - +$.66 Respite Care rr Level 1 1/2 $9.86 day/$300 mo -------------------- ---------
r ($23.67 day/$720 mo) N 1.,:0;
t R ms's
$26.30 Level 2.. $11.51 day/$350 mo `(p Level 2 $9.86/$300 mo t4�s
n i.
ii
+$.66 Respite Care - Occasional crisis intervention as needed, Weekly scheduled therapy, �;t
2 }, , o-. k R Level 2..$4.47
($26.96 day/$820 mo) t; two face-to-face visits with child, c' 5-8 hours a month with 4 hours of e,
itNii 2-3 contacts per month group therapy.
IV
$29.59 1: �"k
2 1/2 . +$.66 Respite Care VA
��' Level 2 1/2 $13.15 day/$400 mo --------
witti ($30.25 day/$920 mo) t
$32.88 Level 3 $14.79 day/$450 mo 4.1 Level 3 $14.79/$450 mo '24 7.
iii..
Will
fire +$.66 Respite Care P Ongoing crisis intervention as needed, aii Regularly scheduled weekly ' ,.
3 multiple •sessions,can include Level 3..$6.02
weekly face-to-face visits with child, r; more c ,
a° ($33.54day/$1020 ma) Tqi 14 1'g
Mrti
and intensive coordination of ce.41 than 1 person,i.e.family therapy,
44; tot multiple services. 10 for 9-12 hours/monthly.
$36.16
3 1/2 +$.66 Respite Care s...? Level 3 1/2 $16.44 day/$500 mo `l ------- --------- Al , ----..
MT
($36.82 day/$1,120 mo) , d ';.cigii Ai: .a
s
$39.45 `l Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo a Y.:
icyl
1.
+$.66 Respite Care Ongoing crisis intervention as needed p Regularly scheduled weekly ,,-
4 r.; _ ',,y,;, multiple sessions,can include zs
TRCCF which includes high level of case '' more Level 4....Neg.
Drop Down
- r
($40.11 day/$1220 mo) management and CPA involvement with ,g than 1 person,i.e.family therapy,
il child and provider and 2-3 face-to-face tr€,f�? for 9-12 hours/monthly. t
p
1'4i contacts .er week minimum.
Assess/ Icri
Emergency $30.25 day/$920 mo ri4 $13.15 day/$400 mo --------
Levelii lila 44;
(Includes Respite)
Rate
kg; yl 414
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendui
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to th ;".• ` WELD COUNTY BOARD OF
El® SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
•
DEPARTMENT OF HUMAN
1 �F•".4O
semi :���� �� SERVICES
By BY Ci iyj (�ry
Deputy ' erk to the Boar."te Chair ignature
SEP 2 0 2010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Kids Crossing
OF HUMAN SERVICES 1440 E Fountain Blvd
Colorado 1 Springs, CO 80910-3502
ad
B : o By: 1. Area✓ �j 0ltetb—
ector
o?L10 cQ/9
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Lutheran Family Services of Colorado and Weld
County Department of Human Services for the period from e9t
July 1, 2010 through June 30, 2011. �G6'�
04f
The following provisions, made this / day of , 2010, are added to the referenced �/
Agreement. Except as modified hereby, all terms t Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the CPA identified as Provider ID#45080. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Section I, Paragraph 4. Transportation may include, but is not limited to;visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
6. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
7. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
o?C/C— ?/94
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 I ID
OB
CASE ID DOB
WORKER COMPLETING ASSESSMENT 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 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
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑I)Once a month 01%)Two times month
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?
O Basic Maint.)No educational requirements ❑I) Less than a'/z hour per day ❑1%)'%hour a day
O2) 1 hour a day O2 %z) I'/z-2 hours per day O3)2'/z-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
❑3)Constant basis during awake hours O3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond aee appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week O11/4)5 to 7 hours per week
O2)8 to 10 hours per week O2%) I1 to 15 hours per week ❑3) 16 to 20 per week
❑3'%z)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.
❑1'A)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3) Face-to-face contact weekly with child and occasional crisis intervention.
O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a 8.1 to this child.
tai sv. xa +"91 . re `. fivY� r + , §. ro
y� a`r n r 7 �k w: ; 'r. "-
°.5 a a ljCil"'.,a -^"*k:u.x"'ssa e & �f. ..:s,.....A,z ,..,re a�,.* `"w�¢t l ,.,,₹'__ .. tH..e.:'};, .,... . .. ...
Aggression/Cruelty to
Animals ❑ ❑ 0 0 ❑ ❑ ❑
Verbal or Physical
Threatening ❑ ❑ ❑ ❑ 0 0 ❑
Destructive of
Property/Fire Setting 0 0 0 0 0 0 0
Stealing
❑ ❑ ❑ ❑ ❑ ❑ ❑
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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ n ❑ ❑ ❑ 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:::rvices that a..l to this child.
r ��$�° + f Xte+ ' §t ° e§awe.o'aa ' *s,f c' ° y r".�i '"rfc� " ' a x x.:4
§ sus x}} m za'{s*3 ,krowu'4 ,7 a w '"�tI,',Pn 6 - n 1'
i Ia
y* P +'t_§ 9*�*44 �Fl:t.4 ` 3 ,x { $T¢w 5a ° 'Y b t ' x •?. i Y I S• i
jilMa �, r o- : a�.�l *, ' " + ' , m' ,,5 °hyk1. � a i 5
+g "� : r x a t8 `f vt # 771, ,'q , AA {.wi x`(4 ':!Sr *: :: a t Y ./..,,,:i4,1
g k xa s §a.:t 5 i,avks 4 4 a 2';:'P +`}9c r: r., : D r ti } ' Pv ��,,
t iiiglf .g e amVin �.aR,3�?}.C�ta#a 4 s M 'S kye„rhyu'S3 ,ix a: a ?. '% a.
L'.m �„`kM`'a.x't r.;'�. ,t.. .. A.;.`,.�'..e YtSis x $."�'tuae...'.``ds.�'Ek a.�, , d,��".,rn�'�a. 4. v, . v� ."� n.�.. e, v,. . ffi.x ..__.._`.. r�n3.q ;
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ 0 0 ❑ 0 0 0
Delinquent Behavior
❑ ❑ 0 0 0 0 0
•
Depressive-like Behavior
❑ ❑ ❑ ❑ 0 0 0
Medical Needs
(If condition is rated"severe", ❑ 0 0 0 0 0 0
please complete the Medically
fragile NBC)
Emancipation
❑ 0 0 0 0 0 0
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ ❑
•
Boundary Issues
❑ ❑ 0 0 0 0 0
Requires Night Care
❑ ❑ ❑ ❑ ❑ ❑ n
Education
❑ ❑ ❑ ❑ ❑ 0 0
Involvement with Child's
Family 0 0 0 0 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'/a ❑ 2 ❑ 21/4 ❑ 3 ❑ 3'/2
6
Weld County SS-23A Addendum
•
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
.i } 4 °° a 4"s M, •a a tia{ a a
m t � � fr � �.�, a -d° • , a� w r7 c a a �
x. 4 "�a � � � a r ar lz 3a x e
:sz"C"• 1�is t4. 'a b,..x .� hrfr.: ks 4 .w°5 ._; . +7x a 4'
4•'r -2,3r'g'x�e =', i', #' �'s ,� i : i + • •arikkg,(*'a. s�.+ .&± ,f .a;. .,,,,,a. a.j�a....,.. e+�"•. ....,:'a.;"�."InH..a rv.!,w .re4''t�,, k.s, ' .$.,.v-,.rt. . •• s1�4",., . es .. ..°° .,...a.2s
.. Age 0-10...$16.32 i 1-',;:C.; cy a
($496) v, 1 Basic Maint $4.93 day/$150mo 2 Level 0 $0 '"a"�,
County Ts Age 11-14...$18.05 'r '= Therapy not needed or provided
Basic ($549) No crisis intervention, Minimal CPA by •: Level 0..,$0
Mamt614 Age 15-21...$19.27 cR: (None)
fka ($586) 3 involvement,one face-to-face visit AAA! another source, i.e.mental health. TA.;
+$.66 Respite Care I# °
HA
. ,A ($20) ,*h with child per month. `
OS $19.73 Level I $8.22 day/$250 moll IT Level 1 $4.93/$150 mo .
u
4,04 +$.66 Respite Care '4,r' Minimal crisis intervention as needed, Regularly scheduled therapy, 1,4
1 ft 144one face-to-face visit per month with a ' ; . Level 1 ...$2.99
($20.39 day/$620 mo) child, A.A. up to 4 hours/month. ,�.� ?
2-3 contacts per month AAA
$23.011= ( .•
p.
1 1/2 +$,66 Respite Care Level 1 1/2... $9.86 day/$300 mo "- AAA
($23.67 day/$720 mo) -- ')1
4 ky
$26.30 Level 2 $11.51 day/$350 mo s`iti Level 2 $9.86/$300 mo
2 +$.66 Respite Care it Occasional crisis intervention as needed , Weekly scheduled therapy, r
Level 2..$4.47
ki. ($26.96 day/$820 mo) ll two face-to-face visits with child, 5-8 hours a month with 4 hours of :M'1
ift
4.4
2-3 contacts per month group therapy.
will $29.59 04• .'m
rA
2 1/2 +$.66 Respite Care T'a• Level 2 1/2 $13.15 day/$400 moet. ---- ----------- 'k - ---------
� lt. ($30.25 day/$920 mo) '
Ill 01
$32.88 44 Level 3 $14.79 day/$450 mo 09 Level 3 $14.79/$450 mo "w
.61 +$.66 Respite Care i Ongoing crisis intervention as needed, 5 Regularly scheduled weekly 'Afis
1
*111 ' ' multiple sessions,can include
3 `� p Level 3..$6.02
a weekly face-to-face visits with child, a more
M ($33.54day/$1020 mo) 14,0, and intensive coordination of than 1 person, i.e.family therapy,igz
,:41multiple services. for 9-12 hours/monthly_ '*9
$36.16 n '
gigN
3 1/2 IAA +$.66 Respite Care Level 3 1/2 ........$16.44 day/$500 mo 141
All ($36.82 day/$1,120 mo) _1 °`.=!
6rr
$39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo ,
1
+$.66 Respite Care AlOngoing crisis intervention as needed, ';`�i Regularly scheduled weekly ,
4 5 <' 111A. multiple sessions,can include
which includes high level of case ° i^. more ;
TRCCFLevel 4....Neg.
Drop Down ' _`
($40.11 day/$1220 mo) II management and CPA involvement with than 1 person,i.e.family therapy,
4 child and provider and 2-3 face-to-face " for 9-12 hours/monthly.
h;u contacts •er week minimum. Ato
s :
Assess/
1'
Emergency $30.25 day/$920 mo $13.15 day/$400 mo _______---------s .a -------- a,.
Level (Includes Respite) _-ittl ,
FAA 3Rate 's' a .
�_ y1:sM:
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
I►'�+�� SOCIAL SERVICES, ON BEHALF
/� 1E,La OF THE WELD COUNTY
�/ �, DEPARTMENT OF HUMAN
"ti�Mt till ��� SERVICES
By: ��I BY 0 GLA—
Deput Clerk to the Boar:%a .,i► / Ch 'r Signature
SEP 2 0 2010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Lutheran Family Services
OF HUMAN SERVICES of Colorado
, e
Fort-Collins, CO-80525 !
363 Snm4 � �W
grc. , ,7uirtoZDO
17Eivvt.C co foda,b
By: By
i ector /J
8 Weld County SS-23A Addendum
• WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency ices
(the"Agreement") between Maple Star Colorado and Weld Cou ty?9
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 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#90967. 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
cX717-9195
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# SEX F TRAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT rlu# I DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I PROVIDER TRAILS I ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P I. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week 01)One round trip a week ❑1%2)2 round trips a week
92)3-4 round trips a week. ❑2%)5 round trips a week 93)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
02)Three times a month ❑2%)Once a week 03)Two times a week
❑3'h)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''/2 hour per day 011/2) 1/2 hour a day
02) 1 hour a day 02 %) 1'/,-2 hours per day 03)2'h-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 ❑1) Less than 5 hours per week 01%)5 to 7 hours per week
❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3%a)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 ❑1/)5 to 7 hours per week
92) 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
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.
O 2)Face-to-face contact two times per 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?
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
4 Weld County SS-23A Addendum
(Exhibit B)
•
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that al 81 to this child.
r v • } r ay. s,„.,
dy
�$1.1Yy�'� K t } ^u".
raw .,.�;., ',,. vv r.,.:2^ �a....:a'€;'*' ° ;ra� r ro t v s . ,.i: ' re...ri�S+n+r�Qa4mvN 4t .r,2�: � . . . . .. ' ' +�. vk. a..:... .=a:„,.t. �s,:
Aggression/Crnelty to
Animals ❑ 0 0 0 0 0 0
Verbal or Physical
Threatening ❑ ❑ 0 0 0 0 0
Destructive of
Property/Fire Setting 0 0 0 0 0 0 0
Stealing
❑ ❑ ❑ 0 0 0 0
Self-injurious Behavior
❑ ❑ ❑ ❑ ❑ ❑ 0
Substance Abuse
❑ ❑ ❑ ❑ 0 0 ❑
Presence of Psychiatric
Symptoms/Conditions 0 0 0 0 0 0 0
Enuresis/Encopresis
❑ ❑ 0 0 0 0 0
Runaway
❑ ❑ 0 0 0 0 0
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
5 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that a..I to this child.
r x n . ya *. 't
.
"Sirk: 'x'la.'`pie Csk 4 F. a
''s,
'Ii.
a ���"a.,t+a..u3:a�� i+a, �'. _ e�.�$au.. ,.�..<..i.._ a .w .. �,•..,. T 4.4., o �_ :,.... . ..:- ..'F .... .. ... . .. .. ..... ....x �...
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ ❑ 0 0 0 0 0
Delinquent Behavior
❑ ❑ 0 0 0 0 0
Depressive-like Behavior
❑ 0 0 0 0 0 0
•
Medical Needs
(If condition is rated"severe", 0 ❑ ❑ ❑ ❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ ❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues
❑ 0 0 0 ❑ 9 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 ❑ 11/2 ❑ 2 ❑ 2''4 ❑ 3 ❑ 31/4
6 Weld County SS-23A Addendun
•
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
1
b .
1SY4yqgr
i R
4* .„ ...,.e.: t •• .-:.
*$ Age 0-10...$16.32 _ .�
($496) f. Basic Maint $4.93 day/$150mo iiiwti Level 0 $0
County Age 11-14...$18.05 Therapy not needed or provided 3`
Basic ($549) g 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
($20) with child per month. era
v
$19.73 ":. Level 1 $8.22 day/$250 mo .y Level 1 $4.93/$150 mo
!Ii +$.66 Respite Care • Minimal crisis intervention as needed �,'. Regularly scheduled therapy, a y
1 y f ^= d Level 1 ...$2.99
. :4 + one face-to-face visit per month witha:a
.;,s child, `t`.G up to 4 hours/month.
,,-, ($20.39 day/$620 me) � ,
2-3 contacts per month `
�' $23.01 .•. 3, :
1 1/2 +$.66 Respite Care Level 1 1/2.........$9.86 day/$300 mo ,'_, ----------------------- '. ________
AT ($23.67 day/$720 mo) oi,
3 $26.30 ₹'.. Level 2 tisk
$11.51 day/$350 mo Level 2 $9.86/$300 mo i
1 +$.66 Respite Care - Occasional crisis intervention as needed, Weekly scheduled therapy,
2 �x „ c:1.(::::::! 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) y* a, $
k. 2-3 contacts per month + group therapy. AU!
Y $29.59 ^`.n #sa
21/2 +$.66 Respite Care ......$13.15 day/$400 mo - -- ---- 1',
($30.25 day/$920 mo) 1'r' ,Attf ---- ---- ilt,
Nom. $32.88 Reg t. Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo
+$.66 Respite Care } - Ongoing crisis intervention as needed, i Regularly scheduled weekly `^ "
3 :;t (Lt.':
multiple sessions,can include Level 3..$6.02
ttia ≥' weekly face-to-face visits with child, t°:..py, more ^y,e
($33.54day/$1020 mo)
t nA and intensive coordination of 'h`,-: than 1 person,i.e.family therapy, .,xre
f.-1. multiple services. `«$ for 9-12 hours/monthly.
o:uoi,.% di'.'
$36.16 1 '
.11
3 1/2 i +$.66 Respite Care Si: Level 3 1/2 $16.44 day/$500 mo ?w ------....----- "
($36.82 day/$1,120 mo)
d:: +61'14
$39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo s
+$,66 Respite Care t Ongoing crisis intervention as needed, Regularly scheduled weekly t
El y a, multiple sessions,can include ::
7RCCF lip which includes high level of case z+ more ,i, Level 4....Neg.
oe
Drop
Down ($80.11 day/$1220 mo) management and CPA involvement with t(y£ than 1 person,i.e.family therapy, eew
child and provider and 2-3 face-to-face riii for 9-12 hours/monthly. .<
contacts •er week minimum.
•
Telki
Al
ill Assess/ Ni
Emergency $30.25 day/$920 mo `y - +`
9 Y Y as $13.15 day/$400 mo - it
Level Rate • (Includes Respite) s. i
im
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
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 Bead WELD COUNTY BOARD OF
Nemo'� s �` SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
0` la DEPARTMENT OF HUMAN
' u, t "; k )m SERVICES
By: IC
Deputy *Perk to the Board / Chair ignature
SEP 2 0 2010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Maple Star Colorado
OF HUMAN SERVICES 2250 S Oneida Street, Suite 100
Denver, CO 80224-2557
B :
irector
ac/n-airy
8 Weld County SS-23A Addendum
, • • WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Savio House and Weld County Department of 406' �
Human Services for the period from A
July 1,2010 through June 30,2011. 26
The following provisions, made this j day of , 2010, are added to the referenced
Agreement. Except as modified hereby, all terms o t 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#37330. 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.
07()//)---c)/95/
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 F [MAILSIAILS CASE ID rOB
WORKER COMPLETING ASSESSMENT 1HH# I 1DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week 01)One round trip a week ❑1'/:)2 round trips a week
02)3-4 round trips a week. ❑2'A)5 round trips a week 03)6 round trips a week
❑3%:) 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
02)Three times a month 02%)Once a week 03)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 Du Less than a'/hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 /) I'1-2 hours per day 03)2'/r3 hours per day
❑3'/z)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 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
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming, physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) I I 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.)
❑I)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑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) DI)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..! to this child.
+ ry a n;+ a.4 .� ` .1g''r : t,, ; :.•.. ,�,a++, A - ',. Ir.:1-Y'#:0-h t �` `£ h a,t* R+';P , 'Y'vj�,O 7, t 's S2 ,y u' i* i.
,. :r1ioy: itt�. irsa4``�saThr"" .,"x.E.,.° A.
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
❑ 0 0 0 0 0 0
Self-injurious Behavior
❑ 0 0 0 0 0 0
Substance Abuse
❑ ❑ ❑ ❑ ❑ 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 0 0 0 0
Enuresis/Encopresis
❑ ❑ 0 0 ❑ 0 0
Runaway
❑ ❑ 0 0 0 0 0
Sexual Offenses
❑ 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 wh1iich create the need for services that a..I to this child.
: `^ .,::•••.......•y; s !x s`i 'i � `��ir * #�' fry ; :i`*<,": .,,
C
t as v,y_ i :,:t1-:-E" :4'", '''i p'r 's .v" �'§p'
"{r "sa c as • •" rv +*,. sk x e0 c`-: .' ' a ; " .k5 j. i d ,�`,A
x "`. A.ap '� -::-""e 9-fat p t 9Pre. Y a.wp'k"re } Lath; 8 S kv , .;:7:1•17,
� � '^4
a�r'�s r r " .`y =y i ug,� a 'p'aP J� xi ' p$i n y ,, 5
$°:litkrib I:y;. ''., :.•:% is .r ir2'n$' r,..-:.:::•-• 4 4 . Y �'kee i t' :k yft.,: :. �, #"l Ie; . v .y ,1e an '° „s'}s9;4 a s' ) €. +4 �` `'si
�?'36 ., d . .''aa ii °iS PN , !t9i''d.,xaxa 4a }A°5�Y3" '4 .. Jta'F,PX4 S. �?.t.k .-:. • , _. c. : a L t h A.�, ".y . .
Inappropriate Sexual O O O O O 0
0
Behavior
Disruptive Behavior
O 0 0 0 0 0 0
Delinquent Behavior
❑ 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 0 0 0
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ ❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ ❑ 0 0
Boundary Issues
❑ ❑ ❑ ❑ ❑ ❑ ❑
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 Ell El 1'h ❑ 2 ❑ 2'/z ❑ 3 ❑ 3'/s
6 Weld County SS-23A Addendum
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
'* p.�.t ` ,' ." -t S ' ;^t r ri, x` Cr :� -`'_ 3're
,.::::91;;I:14.301:11. $�§°3F�' '•xe 5� r :i ". .,:14:1,-..;;,'.'5.../07.1000.00:000,.000.00.0.4100,.t :f c ¢ a s+Ff a.t¢ v 00i0;01001•000,0.0-0, . (h
04 �0 a rry � 100.i`4n" ,+} 5, v{: 000, a. •*` is "Yya ( ^ a r0
} ' 6,Iq,zf i gWVI,,i .;:. 00 1 .'5 ' ;."0-10.0000040.0 00.0; ,xt Agra u.;£t.,.r gi x +;�.�4j . '1 :T € r: .,000.40000:0:000000
"5
Sya 1 + i x ' :h a00 ai 0:' 'kF." . ` ' 0 ."t + 0'0000 00; ,k. X100 010$ ." .n ri tai `§ a ; afa t''.: <$₹ '"a �a 0,200/7,001.00,0,0:4* . y :d: 4000., ,.;000.00,....,.,,,,c4,,,,44; i.,1 a °`:+
�* rB. y •sE!' .wv,+ f�.� 't xr+,,.;,• .s �a�... i 1kw�.�., ;+' �,.�, �;
Tifili
ktiit Age 0-10...$16.32 - �,
($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 ra 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 lat wii ii'Z'
($20) II& with child per month. Pt
ti $19.73 -'�°" Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo r
klha +$.66 Respite Care ., Minimal crisis intervention as needed, s,' Regularly scheduled therapy, nA t
1 one face-to-face visit per month with ,. . Level 1 ...$2.99
($20.39 day/$620 mo) child, '" up to 4 hours/month. ' )
7,18 2-3 contacts per month ii
$23.01 i, . ail ,
1 1/2 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo ---------------- ,
--- �`'
($23.67 day/$720 mo) :,,e,, t
.': $26.30 Level 2 $11.51 day/$350 mo A`e Level 2 $9.86/$300 mo 32
L.3
4.37 +$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy,
2 ,,;: 4 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) .. a
tat
tk. 2-3 contacts per month group therapy. In/
tWI $29.59au 1
raiPiii �s;
2 1/2 liw.," +$.66 Respite Care 4004. Level 2 1/2 $13.15 day/$400 mo MI i
Pilti ($30.25 day/$920 mo) Rig iitittt,a Os re: ,yflizy .
itM $32.88 .s Level 3 $14.79 day/$450 mo j Level 3 $14.79/$450 mo I.
+$.66 Respite Care 14 Ongoing crisis intervention as needed, Regularly scheduled weekly WV
multiple sessions,can include ;"
3 o . Level 3..$6.02
weekly face-to-face visits with child, more
($33.54day/$1020 mo) AAri and intensive coordination of than 1 person,i.e.family therapy, ;_
multiple services. tilt for 9-12 hours/monthly. '
,, w
$36.16 '
W- EN 00i
31/2 +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo ,,I' --------------------- v..m
ro
($36.82 day/$1,120 mo)
4'.S_ CM
r,:? $39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo ?°.
+$.66 Respite Care Ongoing crisis intervention as needed, ctik. Regularly scheduled weekly
4VA 0 multiple sessions,can include
TRCCF �. which includes high level of case more Level 4....Neg.
Drop Down ,i._: ,Xa4 Ct
($40.11 day/$1220 mo) management and CPA involvement with than 1 person, i.e.family therapy, „•
ta 1,1
ro child and provider and 2-3 face-to-face for 9-12 hours/monthly.ki
*x
a m contacts •er week minimum. sw.r?t ,
AstAssess/ la „eu
Emergency lqt $30.25 day/$920 mo yi $13.15 day/$400 mo .24
----- ------------------ wa
1
Level (Includes Respite)
Rate ; `c
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 t ; WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
Ilk OF THE WELD COUNTY
�. ,. DEPARTMENT OF HUMAN
1 ism ;� SERVICES
By: 4 y ! � �srl� By:C 196 C�. a —
Deput I erk to the Boars Chaff Signature
SEP 2 0 2010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Savio House
OF HUMAN SERVICES 325 King Street
Denver, CO/Li 8// /�J0''219
By: C By: /�
D'r ctor
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Smith Agency Inc. and Weld County
Department of Human Services for the period from
July 1,2010 through June 30, 2011.
2010 JUL nor 21 P l: 214
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.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the CPA identified as Provider ID#44882. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. County and Contractor agree that for Children's Habilitation Residential Program
(CHRP)waiver eligible children, the County agrees to pay the federal SSI rate to
Contractor and all other service costs will be billable under the CHRP program.
4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
5. Section I, Paragraph 4. Transportation may include, but is not limited to; visitation with
family members, medical/dental or mental health appointments, extracurricular activities,
court hearings or other specialized programming. Transportation expectations will be
documented on the Child Specific Addendum, SS23B.
6. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
7. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
8. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
ace-02/99
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# SEX ITRAILS CASE ID mDOB
M F I
WORKER COMPLETING ASSESSMENT IF1H# PATE 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 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 ❑1A)2 round trips a week
❑2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week
O3%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required ❑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 01
special education plan?
❑ Basic Maint.)No educational requirements 01)Less than a''/ hour per day ❑1''/) '/ hour a day
O2) 1 hour a day O2 %) 1'/r2 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 ❑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
O 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 ase appropriate needs with feedin
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
❑3%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'%) Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two timesper month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
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 Addend
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child.
ham' ''$'°m:ti.0.t; +1q x t' � f ':a-/, n 1 a a , i y •,:::{r
x €.
m' v+{ �'� �a`�'�.,1s �"r �' .fix ' � "'x s.. t =.:s
iv Tr: A `��t a F 7.-:-.,4;.... ,,,,,-, , :r y3 p
rr L rt t s ...•_-u'.... _ .₹"+'5R.$' v.Y u..u1 # ' # "‘4.,:c...'. '.."-;:1,';,izi ;&)x '.'W. ":A }.
Aggression/Cruelty to
Animals El 0 0 0 0 ❑ 0
Verbal or Physical
Threatening 0 0 ❑ 0 0 0 0
Destructive of
Property/Fire Setting 0 0 ❑ 0 0 0 0
Stealing
❑ ❑ 0 0 0 0 0
Self-injurious Behavior
❑ 0 0 0 0 0 0
Substance Abuse
❑ ❑ ❑ 0 ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 0 0 0 0
Enuresis/Encopresis
❑ ❑ ❑ ❑ ❑ ❑ ❑
Runaway
❑ 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.
r� r. ty +4. 3 r v e '. ar: r-11::07:.:.‘ t } +;
f
'"s ?•i 5' .`i 7 h`t ykYl L f-: k:
} i
4-sr t s rr.•:.:,..- :f t-^...1.4..;.4....-,..-4::,., f r•I" v. a Mc•t5 grsc y,. yetl.y
„hJ :4w.. 1w "It.x... : a• .. M• .. .. r .f..... r.m.xx..
Inappropriate Sexual
Behavior 0 0 ❑ 0 0 0 0
Disruptive Behavior
❑ 0 0 0 0 0 0
Delinquent Behavior
❑ ❑ ❑ ❑ ❑ 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
Eating Problems
❑ 0 0 0 0 0 0
Boundary Issues
❑ ❑ 0 0 ❑ ❑ ❑
Requires Night Care
❑ 0 ❑ ❑ ❑ 0 0
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
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 ❑ 11/4 ❑ 2 ❑ 21 ❑ 3 ❑ 3'/z
6 Weld County SS-23A Addendum
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
' r i t - di
'�S ?,;i:l`ti's ,Di awi` :: _ .. 'l ti . l .,s Q'il' ...:•-.:4 ..L!ii.i.d4 ......'u.;�{ .vi.l k: •.x .c . ,.r:'..:
Rr 't Age 0-10...$16.32 1 `
($496) r' Basic Maint $4.93 day/$15omo t: Level 0
County Age 11-14...$18.05 Ill :; Therapy not needed or provided 't rA
_, ($549) No crisis intervention,Minimal CPA ltd' by ;ill Level 0...$0
BaMaint. .'` Age 15-21...$19.27 ' , Min sti 1 i{, (None)
($586) involvement,one face-to-face visit Tiiil.i another source, i.e.mental health. t
+$.66 Respite Care
+"�;t. ($20) with child per month. 3 3 '"
it aw n6 , 4
Allii $19.73 Level 1 $8.22 day/$250 mo i:ti Level 1 $4.93/$150 mo
410 71t 2"
+$.66 Respite Care ` Minimal crisis intervention as needed, Regularly scheduled therapy, `1
1 'lig Level 1 ...$2.99
one face-to-face visit per month with x4, .}m
tip ($20.39 day/$620 mo) i child, up to 4 hours/month. A:,�e
.. ' # 2-3 contacts per month '
$23.01 .°'c, s
kit n
1 112 +$.66 Respite Care Vim. Level 1 1/2 $9.86 day/$300 mo -: r --------------
4 ($23.67 day/$720 mo) :t'
"'
$26.30 till Level 2 $11.51 day/$350 mo .i.:;,:: Level 2 $9.86/$300 mo •, ;
2 +$.66 Respite Care DI Occasional crisis intervention as needed, Weekly scheduled therapy,
hit Level 2..$4.47
` two face-to-face visits with child, }c�: 5-8 hours a month with 4 hours of f
°W ($26.96 day/$820 mo) r , .ez :3 }
s 2-3 contactsper month {"
ke group therapy. �}
a $29.59 fr. ts,,c• llii R r:;!
2 1/2 +$.66 Respite Care °4' Level 2 1/2 $13.15 day/$400 mo �5
($30.25 day/$920 mo) `"
414.
: $32.88 0 Level 3 $14 79 day/$450 mo Level 3 $14.79/$450 mo
StI
Nkili
+$.66 Respite Care ` Ongoing crisis intervention as needed, `: Regularly scheduled weekly
3 aid a multiple sessions,can include
weekly face-to-face visits with child, Tti more � ' Level 3..$6.02
44) k
($33.54day/$1020 mo) a
fa ,xoe and intensive coordination of than 1 person, i.e.family therapy, "lal ivli
har „';1 multiple services. q' : for 9-12 hours/monthly.
f:i"4 •*„..$36.16kii.3 MO
3 1/2 WI. +$.66 Respite Care '3*.liR. Level 3 1/2 $16.44 day/$500 mo ? — NAN
($36.82 day/$1,120 mo) 14
"9
yi
$39.45 mil Level 4 $18.08 day/$550 mo a Level 4 $14.79/$450 mo OA
Ili
+$.66 Respite Care Ongoing crisis intervention as needed, Regulary scheduled weekly s
4 a irrwl multiple sessions,can include ."
which includes high level of case i more t5
TRCCF 9 , W Leve14....Neg.
Drop Down :ti • management and CPA involvement with ta„ than 1 person,i.e.family therapy,
($40.11 day/$1220 mo) S.
.g ; a1
mi child and provider and 2-3 face-to-face for 9-12 hours/monthly. .
' contacts .er week minimum. O.11
w
Assess/ 144 Pi4
Emergency $30.25 day/$920 mo i .
Leveliii (Includes Respite) rig $13.15 day/$400 mo .rt ---------
Rate "
._ o a
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF
+y, SOCIAL SERVICES, ON BEHALF
IE IL®% OF THE WELD COUNTY
DENT OF HUMAN
ERARESI tittái1
i Fr ftmmei
By: f,.e�/ L >' s. .d�_��4R: ei�lalc, 1 By: 90j D Q aur
Deput lerk to the BoarNt I < Cha Signature
SEP 2 0 2010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Smith Agency Inc.
OF HUMAN SERVICES 7169 S Liverpool St
Centennial, CO 80016
By: Y:
Di ector
, &dum
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Special Kids Special Families and 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. P9
9fr
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#43184. 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
&C/G- c2/9%/
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# FEX F ID
OB
CASE ID DOB
I
WORKER COMPLETING ASSESSMENT HH# I 1DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1%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
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
O Basic Maint.)No participation required ❑1)Once a month 01%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
03%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements 01)Less than a ''/2 hour per day 01%) 1/2 hour a day
02) 1 hour a day 02 %) 1'/2-2 hours per day 03)2%-3 hours per day
❑3'/2)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
02)8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
El 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
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.
7:::-.1,:. - YCA
}ass 'r!::::;;11::11::::`'
_ 6#x,{�nitris'` %41:-.:4'.
: 3z
�a"e4.,.4i ��'�v*����x. � ��� "�.�,. �.«.v&4 ..��"k�r rii,i$.x3f u`...}'tP..Y r*�u apt 1..t�w$r1.ro
Aggression/Cruelty to
Animals ❑ 0 0 0 0 0 0
Verbal or Physical
Threatening 0 ❑ 0 0 0 0 0
Destructive of
Property/Fire Setting 0 0 0 0 0 0 0
Stealing
❑ 0 0 0 0 0 0
Self-injurious Behavior
O 0 0 0 0 0 0
Substance Abuse
O 0 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 0 0 0 0
Enuresis/Encopresis
❑ ❑ ❑ 0 0 0 0
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ 0
5 Weld County SS-23A Addend
(Exhibit B)
• WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child.
-r t t o n`a 7�Iry t 'a'" r ,,, °_' '" ^.a e
'f P 5i } P .. '' A f tv t r)
'''$'A� ^,tfe °ye. } ' ^i Y=. .t°, ,, „ vats .! e ti
n �"d ≥:v n..wk�u.aata a �. �ks� .' t€ I?,...$ 3 x +.:.`:.�. sh.x.,'.� a"...st€ �.... Aar. _ .•., {` .
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ 0 0 0 ❑ 0
Depressive-like Behavior
❑ ❑ ❑ ❑ 0 0 0
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
Boundary Issues
❑ ❑ ❑ ❑ 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
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ PA ❑ 2 ❑ 2/ ❑ 3 ❑ 3'/z
6 Weld County SS-23A Addendun
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
Tt
¢''Vest, .hw 11'N. r .o-k r
Age 0-10...$16.32 '
($496) Basic Maint $4.93 day/$150mo Level 0 $0 a;
County Age 11-14...$18.05 '1 7,:;1. Therapy not needed or provided Fix=
Basic ($549) No crisis intervention,Minimal CPA yF by n n. Level 0...$0
Maint. Age 15-21...$19.27 *' (None)
($586) : involvement,one face-to-face visit 7 another source, i.e.mental health. '
ioll
+$.66 Respite Care * s-. ,^.
11 ($20) with child per month. ,.
$k $19.73 5 Level 1 $8.22 day/$250 mo J;? Level 1 $4.93/$150 mo
', +$.66 Respite Care t Minimal crisis intervention as needed " Regularly scheduled therapy car
1 one face-to-face visit per month with t :., Level 1 ...$2.99
x ($20.39 day/$620 mo) child, ;, up to 4 hours/month.
A 4 2-3 contacts per month sir).•',
.i:. $23.01
1 1/2 :::.!iii:
+$.66 Respite Care 2 Level 1 1/2... $9.86 day/$300 mo S. , --------------------- ---------
^�' ($23.67 day/$720 mo) .fir ,,: ;
"�; $26.30 r`••; r"
Level 2 $11.51 day/$350 mo ra, Level 2 $9.86/$300 mo ' b"
2 +$.66 Respite Care s .: Occasional crisis intervention as needed, 'aa�. Weekly scheduled therapy, ::
.�' .il lw e: Level 2..$4.47
a two face-to-face visits with child, 5-8 hours a month with 4 hours of 1
r " ($26.96 day/$820 mo) 41O �;
;Vi=i± 2-3 contacts per month group therapy. °'
,;(.: $29.59 `"' +.
21/2 "1' +$.66 Respite Care ,,, Level 2 1/2 $13.15 day/$400 mo -------------------
t",: / �,s Y k'';y
` ($30.25 day/$920 mo) ..1,-,,,,
$32.88 - Level 3 $14.79 day/$450 mo • Level 3 $14.79/$450 mo
''.•:.°;j: ,ii!
i..li +$,66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly .
multiple sessions,can include
3 )' S ,� Level 3..$6.02
,,b., weekly face-to-face visits with child, +,; more .k
($33.54day/$1020 mo) I
and intensive coordination of ₹ .. than 1 person, i.e.family therapy,
ra f multiple services. u.:::. for 9-12 hours/monthly.
$36.16 4$ atS: R[Y.
3 1/2 �.;e +$.66 Respite Care 4,,I.: Level 3 1/2... $16.44 day/$500 mo ,,i --------- ------- �: --------
u
� ($36.82 day/$1,120 mo) � t,l4ie s
Ie k'i'4,4-` $39.45 °4;u' Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
Miti
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly ,
4 1 , multiple sessions,can include a ,.
which includes high level of case more •,.....,:lLevel 4....Ne
TRCCF .I ,. 9
Drop Down 4t', k management and CPA involvement with than 1 person, i.e.family therapy, °
($40.11 day/$1220 mo) s $,
-'t child and provider and 2-3 face to face ' for 9-12 hours/monthly. <_'
contacts ,er week minimum. ,,., ,fir&
Assess! 01 4: !:ji
Emergency $30.25 day/$920 mo ° ''$` ------- .;y
Level VI Rate (Includes Respite)
tag $13.15 day/$400 mo �"
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 t.�fl. .',:..�`� WELD COUNTY BOARD OF
�1 �"® SOCIAL SERVICES, ON BEHALF
r +� l OF THE WELD COUNTY
.`14in
' iii lit:l(1"ts w 1 DEPARTMENT OF HUMAN
'•��•�` "II
SERVICES
BY: ( Pn +1 /i. ralean
�il'�.�. By (c mo cdcr'
Deputy 'lerk to the Board ChaircSignature
SEP202010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Special Kids Special Families
OF HUMAN SERVICES 424 W Pikes Peak Ave
Colorado Springs, C 8090
By: By: '1(A/
D ector
are-,; I y
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Youth Ventures of Colorado and 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 a greement 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#1554849. 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# F.X [MAILSIAILS CASE ID IDOB
I
WORKER COMPLETING ASSESSMENT F1H# I I DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week 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
❑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 01)Once a month 01%)Two times month
❑2)Three times a month ❑2/)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 01) Less than a''/3 hour per day 01%) 1/2 hour a day
O2) 1 hour a day O2 %) 1'/z-2 hours per day O3)2'/:-3 hours per day
O3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed DI)Less than 5 hours per week O1%)5 to 7 hours per week
❑2)8 to 10 hours per week O2%) 11 to 14 hours per week
0 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 ate 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
❑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
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.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3) Face-to-face contact weekly with child and occasional crisis intervention.
O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
O2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child.
.4.`.., `SCC :--31 7-a .4 2 r s.5.. 145--.:-!-C,-...•... P-
'
"`- q y�" a na �'i r rsr ,v ,rte ; £� t .an art nt a r, Bier y₹ri k k:$i i --AP;
.. ssma._ .t C..,«a, x' e.d ux .to 34%. ``x. ii . ..w. «z :'t `av ?..w.,.. .. . _. .._x. _Sn :xs*at' ;S.'
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
❑ ❑ ❑ ❑ ❑ ❑ ❑
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
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑ ❑ 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..1 to this child.
;' .E v.-";17:i.: "I ).mexnk71.1 t' ' Is a"`tt" 'FI`y4u'1 . '4^1 A. s ° - a -..'.4;:.:': i tu.;�
3 �. � ' � — r sr� ' � r � �`ti.
�§" �� `# 7 T 4F s a�`rt,a �"`j4 r s ru '+�� x `5 4 t 4�r � ;•'
."--:~'$t4:
' 'akt' }... r `':??4;i 4 's at + r ='r ‘ '�} �.�� 4e +a'. 4"` s 4. rte.
roxr. °. . . �cq 5 .' t i,sii rri-S : '§ t e s , * ;r3
i i?�...�. t`:,.: 4 {1"� �..,.. e.yv ..rim dt+'?v�.'v " �'‘^uwti4��P.9fip .9c c.!..- ` . . .. z ...,�:� ...,.a x .'eT>t 4$,,.w x.
Inappropriate Sexual
Behavior 0 0 0 0 0 0 0
Disruptive Behavior
❑ ❑ 0 ❑ 0 0 0
Delinquent Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
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
O 0 0 0 0 0 0
Eating Problems
❑ 0 0 0 0 0 0
Boundary Issues
❑ ❑ ❑ ❑ ❑ ❑ ❑
Requires Night Care
O ❑ 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'/z
6 Weld County SS-23A Addendum
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
n '} gi It KRn'&h x°,¢'s,I {�.s s y�'*ay ax..y aa.4;/. �aa a yiz S r • ••,',..1:'-';',4:;,,i,: /,:,';
A„.,,,i4 t' Fx9'' 44"� t i J ] }� h 4 Yn,Y g / 1r
"5 ',t a4 4t+"' '°w q,:? '' t ', +, dim 4 (be .ham s C. l� r t •
7v °-k.4 nl °1 i..'' °k+ii+ '° " ''* i X h ''§ i'' y,k-y§ +. . ,4, .' 0 y
'S '; .,«1t i 3. ?o va . t. .t r#, e^ `''+�" '*y_14,drok 'Se y ° r a
Y ! 4"'3 ' '§k t' ''':;•;;.:;.:1.3,-,,:41'.
5 1,'� �`` i A N i11'1t.,„1','!:',..-...!::)),;,;301.
i' x, ti m;� ^ae"4a' 4.,,a, a., m p t, z°r 4f q xs i§'4 : s q via 1 i 1 a to A ac �t y: a?rv.
.x'a.e' 7 7 x -1Ota "6. .;-'�,�'d- '. ,...Ail....1.4.4,,,,..v...gym na w.,.-<.,J ,.,..„.. K.4 ' 't,.# .;ik x .x:.,12" ..r> 1•".., ! ..'1 sat t}t.,i .`;x. :
:TEA-- Age 0-10...$16.32 r 3'
'9 ($496) Basic Maint $4.93 day/$150mo A+ Level 0 $0 . 'e
County Age 11-14...$18.05 Therapy not needed or provided f
Basic ($549) No crisis intervention, Minimal CPA " by of Level 0...$0
Maint. Age 15-21...$19.27 tt (None)
($586) involvement,one face-to-face visit 4 another source, i.e.mental health
+$.66 Respite Care - a,
($20) with child per month. .'
$19.73 Level 1 $8.22 day/$250 mo Level 1 $4.931$150 mo ``'
:.
+$.66 Respite Care 6l„ Minimal •crisis intervention as needed it Regularly scheduled therapy, 'x°a:
1 ,' one face-to-face visit per month with *fir#a i Level 1 ...$2.99
ENA ($20.39 day/$620 mo) child, .0,fli up to 4 hours/month. s
ea 2-3 contacts per month 'n (a?e
$23.01 " rn $
s'A"&
1 1/2 a +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo -------------- --- , ---------
-
,, ,
($23.67 day/$720 mo) V. "
$26.30 O Level 2 $11.51 day/$350 mo ..;; Level 2 $9.86/$300 mo 'P ''
2 +$,66 Respite Care '; Occasional crisis intervention as needed tt Weekly scheduled therapy, Level 2..$4.47
Pt clA 2-3 contacts per month a
($26.96 day/$820 mo) xitta two face-to-face visits with child, 5-8 hours a month with 4 hours of } ;
group therapy. filtvk'
$29.59lift
^;
2 1/2 +$.66 Respite Care r° Level 2 1/2 $13.15 day/$400 mo Si, . ---------
Si ($30.25 day/$920 mo) al
,
liki.,
=xN is
11
$32.88 Level 3 ialti $14.79 day/$450 molig Level 3 $14.79/$450 mo ' `;
6y
:14::""i +$.66 Respite Care ; Ongoing crisis intervention as needed, Regularly scheduled weekly pg,
3 ,sttvv. multiple sessions,can include Level 3..$6.02
weekly face-to-face visits with child, more
($33.54day/$1020 mo) `
and intensive coordination of than 1 person, i.e.family therapy, #.1
Fr4 PO multiple services. =ell for 9-12 hours/monthly.
lisi
c:
$36.16
3 112 ;0 +$.66 Respite Care Level 3 1/2 $16.44 day/$500 moni r") --------
($36.82 day/$1,120 mo) 4
oat
$39.45 ., Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
+$.66 Respite Care al l Ongoing crisis intervention as needed, Regularly scheduled weekly
4 multiple sessions,can include
TRCCF • which includes high level of case more Level 4....Neg.
Drop Down , management and CPA involvement with than 1 person, i.e.family therapy,
($40.11 day/$1220 mo)
child and provider and 2-3 face-to-face l• for 9-12 hours/monthly. a,
contacts .er week minimum. ..
Assess/ as
Emergency $30.6. 25 day/$920 mo $13.15 day/$400 mo
Level tai (Includes Respite)
Rate dm if oki
ei
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7
Weld County SS-23A Addendurr
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 t SERVICES
S.t� 1b6 t'�
tC e�
By By.
Deput lerk to the � Chair ignature
SEP 2 0 2010
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Youth Ventures of Colorado
OF HUMAN SERVICES 4785 Granby Cir
Colorado Springs, CO 80919
n
By: /
By. 1/4_7,, (//L l zu
r for
9C/C—02/9 V
8 Weld County SS-23A Addendum
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