HomeMy WebLinkAbout20101375.tiff RESOLUTION
RE: APPROVE STANDARD FORMS OF ADDENDUMS TO AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES BETWEEN THE WELD COUNTY
DEPARTMENT OF HUMAN SERVICES AND VARIOUS PROVIDERS AND AUTHORIZE
CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, on May 27, 2009, by Resolution#2009-1219, the Board approved the form of
the Agreement to Purchase Out-of-Home Placement Services and Addendums thereto, and
WHEREAS, the Board has been presented with revised forms of the Addendums to the
Agreement to Purchase Out-of-Home Placement Services between the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Human Services, and various providers, with further terms and conditions being as
stated in said forms, and
WHEREAS, after review, the Board deems it advisable to approve said forms, copies of
which are attached hereto and incorporated herein by reference, to delegate standing authority to
the Chair of the Board of County Commissioners to execute individual agreements and addendums
between the Department of Human Services and various providers.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, ex-officio Board of Social Services, that the revised forms of the Addendums to
the Agreement to Purchase Out-of-Home Placement Services, between the County of Weld, State
of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Human Services and various providers be, and hereby are, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said agreements and addendums between the Department of Human Services and various
providers upon presentation.
2010-1375
LC PS, Cs1-k r HR0081
- -ac-'3
RE: STANDARD FORMS OF ADDENDUMS TO AGREEMENT TO PURCHASE OUT-OF-HOME
PLACEMENT SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN
SERVICES AND VARIOUS PROVIDERS
PAGE 2
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 28th day of June, A.D., 2010.
BOARD OF COUNTY COMMISSIONERS
4iridi> i WELD COUNTY COLORADO
ATTEST:
,gbk � � ougla Radem her, Chair
Weld County Clerk to the Boar
-P`- FUSED
�®( j 4` rbara Kirkmeyer, Pro-Tem
Dep Clerk o the Board -
Sean P. Coy
AP D TO •
Willi . GarCia
County Attorney 4 ucCv
David E. Long
Date of signature: 1 tic)I lb
2010-1375
HR0081
fiftie Zes;sg, DEPARTMENT OF HUMAN SERVICES
P.O. BOX A
GREELEY, CO. 80632
website:ite:
Administration and Public Assistance(970)352-1551
Child Support('9711352-6933 WI O MEMORANDUM
•
COLORADO
TO: Esther Gesick, Clerk to the Board
FROM: Judy A, Griego, Director, Human Services D rime t
DATE: June 22, 2010
SUBJECT: Out-of-Home Providers to be Submitted to the Board of County Commissioner for
Consent Agenda
Attached please find the proposed Weld County Addendums and list of out-of-home providers for SFY 2010-2011.
Please consult with Bruce Barker,Weld County Attorney. These Addendums remain the same from last year and
will be submitted to the Board of County Commissioner for their consent. These Addendums were presented at the
Board's June 21,2010, Work Session.
Directory:
Attachment I—RCCF/TRCCF contract and provider list
Rates are yet to be determined. The Long Bill originally reflected a 2%decrease in provider rates but has belatedly
been reduced due to additional monies available to this line. Currently the State is projecting a 1.48%reduction but
this has not been confirmed. The State will notify Counties of the RCCF/TRCCF base rates via an Agency Letter
that is currently in clearance and should be released shortly.
Attachment II—County Certified Foster Care contract and provider list
Rates arc based the Needs Based Care Assessment and rate table as approved by the Board of Weld County
Commissioners. No COLA is being recommended for the 2010-2011 fiscal year.
Attachment III—Child Placement Agency contract and provider list
Rates are based on the Needs Based Care Assessment and rate table as approved by the Board of Weld County
Commissioners. No COLA is being recommended for the 2010-2011 fiscal year.
Attachment IV—Child Placement Agency Group Home/Center contract and provider list
Rates are negotiated per home/center due to highly specialized care for children who are stepping down from
TRCCF care or cannot maintain in a foster care home setting.
Attachment V—RCCF/CHRP contract and provider list
Rates are based on a negotiated rate per agency due to highly specialized care for children who are not eligible or
who are awaiting approval for CHIRP.
Attachment VI—Specialized Group Homes contract and provider list
Rates are based on the approved rate structure as outlined in DHS policy/procedures manual section 2.308.5. No
COLA is being recommended for the 2010-2011 fiscal year.
Attachment VII—RCCF contract and provider list
Rates are negotiated based on the high level of needs the child requires. These consist of out-of-state providers
where Weld children have exhausted all Colorado resources and facilities that are considered transition/step down
programs for Therapeutic Residential Treatment Centers.
if you have any questions,please give me a call at extension 6510.
2010-1375
Attachment I
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Therapeutic Residential Child Care Facility
Services and Residential Child Care Facility Services (the "Agreement") between
«RCCF_NAME» 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 the Agreement remain unchanged.
1. County agrees to purchase and Contractor, identified as Provider ID#«FACILITY_ID», agrees to
provide:
A. Child Maintenance, Administrative Maintenance and Services, which are listed in this
Agreement at a rate of S«TRCCF_RATE»per day for children placed within the Therapeutic
Residential Child Care Facility.
B. Child Maintenance, Administrative Maintenance and Services, which are listed in this
Agreement at a rate of S«RCCF_RATE» per day for children placed within the Residential
Child Care Facility.
C. Additional services not covered by Medicaid or considered within the above vendor rate. These
additional services/rates may be negotiated on a child by child basis, based on the needs of the
child and in accordance with the Colorado Department of Human Services Agency Letter CW-
06-11-I dated June 8, 2006.
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.
2. Section I, Paragraph 1. County considers the agreed upon rate, outlined in the Weld County Addendum
to this contract, to be all inclusive and shall not pay for additional treatment fees; i.e. Drug/Alcohol and
Sex Offender services.
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.
Reimbursement rates for bed hold days may not exceed the state standard rate for administrative
maintenance and administrative services or may be a reduced rate that is mutually agreed upon.
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. The services purchased under this Agreement as Child Maintenance,
Administrative Maintenance and Services for Therapeutic Residential Child Care Facilities and
Residential Child Care Facilities include, but are not limited to: Food, shelter, clothing, personal needs
and allowance, administration, administrative overhead, support staff, support overhead, sleep-over
staff, direct child care, transportation, therapeutic recreation, service delivery staff, parent training for
teens, independent living training, mentor/advocate, supervised visitation and all other services as
outlined in the Contractor's scope of service attached as Exhibit A or the Child Specific Addendum.
The anticipated minimum percentage for each item is as follows and will be subject to County
monitoring as outlined in Section VI of this contract:
A. Food, including meals and snacks (25%);
B. Clothing (3%);
C. Shelter, including utilities and use of household furnishing and equipment and daily supervision,
including those activities that a parent would normally carry out to assure protection, emotional
support and care of the child (30%);
D. Personal items and grooming care for the child, such as toothpaste, toothbrushes, soap, combs,
haircuts, and other essentials (2%);
E. Other/miscellaneous items considered usual in the care and supervision of the child, include, but
are not limited to, transportation, recreation and overhead (40%)
1. Add Paragraph 8 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.
2. Add Paragraph 9 to Section I. Any additional costs for specialized services, which include, but are not
limited to; polygraph tests, plethysmographs, and urinalysis screens, that is not provided within the
vendor rate or attached Scope of Service, will need be negotiated and authorized, in writing by the
County, prior to the service being performed. Any payment for specialized services not authorized in
writing_ will be denied.
3. 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.
4. 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.
5. Add Paragraph 15 to Section IV. Cooperate with any vendors hired by Weld County Department of
Human Services to shorten the duration of placement.
6. 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.
7. 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 will complete or obtain a completed IEP.
A copy will then be forwarded to the County.
8. 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 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 Human 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.
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 Human 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.
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:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «RCCF_NAME»
OF HUMAN SERVICES «MAILING_ADDRESS»
«CITYSTATE ZIP»
By: By:
Director
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Attachment II
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
«NAME»
and the
Weld County Department of Human Services
for the period from July 1, 2010 through June 30, 2011.
The following provisions, made this day of , 2010, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Provider unless the child is placed in a County certified kinship foster care home or
if the child is placed in a County foster/adoption home as a pre-adoptive placement.
Kinship foster care homes and pre-adoptive placements will be reimbursed at the County
Basic Maintenance level on the Needs Based Care Rate Table, designated as Exhibit C,
regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#«PROVIDER ID». These services will be for children who have been deemed
eligible for social services under the statutes, rules and regulations of the State of
Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
9 Weld County Addendum to the CWS-7A
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
10 Weld County Addendum to the CWS-7A
PROVIDERSHALL:
1. Attend or participate, if requested by the Department, in staffing a child's placement with
the Service Utilization Unit. Provider shall be notified by County staff of the date and
time of the review.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. Cooperate with any contractors hired by Weld County Department of Human Services or
Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. Have medical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Provider. All documentation of
these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. Immediately report to the County Department and/or local law enforcement any known
or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
7. Maintain, access and review information weekly on the Foster Parents Internet Database
On-line System (FIDOS).
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the provider's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
11 Weld County Addendum to the CWS-7A
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
13. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
12 Weld County Addendum to the CWS-7A
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week 01)One round trip a week ❑1%z)2 round trips a week
02)3-4 round trips a week. 02%) 5 round trips a week 03)6 round trips a week
❑3'/:)7 round trips or more
Comments: _
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required DI)Once a month ❑1%z)Two times month
02)Three times a month ❑2'/z)Once a week 03)Two times a week
❑3%z)Three times a week or more
Comments:
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
O Basic Maint.)No educational requirements O1) Less than a ''/z hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 %z) 1'/z-2 hours per day 03)2'/z-3 hours per day
❑3%z) More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ 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 ❑3'/)Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding.
bathing,grooming, physical, and/or occupational therapy?
O Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week ❑1%z)5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2%z) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3'%)21 or more hours per week
Comments: _
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
13 Weld County Addendum to the CWS-7/
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
.. , s SK ehx'5 i r 3 y,." a q. J e
Z. Rating of condttions, 1 _ k N$ t�
(Cheek one box for each category) r g tot `;
`q* ix '.; x�iv,+{3 wx :_ tr..
Assessment A v {
' 'Ci : Mine Mild mild/er Moderate �oderate/Aark Aieh A# sere Comments.
�� €�'r�x Moderate: L.A � ��t t
" 0. 1 ..:11,1/2"r 2 t£ 21nft s, fi7 . :
Aggression/Cruelty to Animals
❑ ❑ 0 0 0 0 0
Verbal or Physical Threatening
❑ ❑ 0 0 0 0 0
Destructive of Property/Fire Setting
❑ ❑ 0 0 0 0 0
Stealing
❑ ❑ 0 0 0 0 0
Self-injurious Behavior
❑ ❑ 0 0 0 0 0
Substance Abuse
❑ ❑ 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions 0 0 0 0 0 0 0
Enuresis/Encopresis
❑ ❑ 0 0 0 0 0
Runaway
❑ ❑ 0 0 0 0 0
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
14 Weld County Addendum to the CWS-7/
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
n.ryj„M s t �., �.5 S �y tr 5't '
-- fx, +A }4 sating of conditions g ','-'2.4.,1,, s f"zd ; '.
(Check one box for each categorx 44.1,44,,,
s t
�:. x: ". “....r
lAsse:t$,,/ Areas* i:4 .
xcl; r v: €y w
s
r7*a a `,. }I'fild/ '1,t .f vt t' a t r 4
k�3 t None d, moderate' Moderad �h* iph I�hlSevere :lie ,4.,
,u� .., � ; . * ,:: � *.- tt t" �-�m
6t ' , 0 - 1 1 1/2 2 k, '21/2 .:3 3" / x xt
Inappropriate Sexual Behavior ❑ El
❑ 0
0
0
❑
Disruptive Behavior
❑ ❑ ❑ ❑ ❑ ❑ ❑
Delinquent Behavior
❑ El ❑ ❑ ❑ ❑ 0
Depressive-like Behavior
❑ El ❑ ❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete the ❑ ❑ CI ❑ CI Ell CI
Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑ ❑ ❑ ❑
Eating Problems
❑ El ❑ ❑ ❑ 0 ❑
Boundary Issues
❑ ❑ ❑ ❑ ❑ El ❑
Requires Night Care
El ❑ ❑ ❑ ❑ ❑ ❑
Education
❑ El ❑ ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑
I
15 Weld County Addendum to the CWS-7.
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) 0 0 ❑1 ❑ 11/4 ❑ 2 ❑ 2'/2 0 3 ❑ 31/2
16 Weld County Addendum to the CWS-7.
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
RECOMMENDED
LEVEL OF SERVICE ,` PROVIDER RATE
P1 -P5
Level Rate
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maintenance
Rate Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment/Emergency
Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
17 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By: By:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: PROVIDER
WELD COUNTY DEPARTMENT «PROVIDER_NAME»
OF HUMAN SERVICES «MAILING ADDRESS»
«CITY STATE ZIP»
By: By:
Director
By:
18 Weld County SS-23A Addendum
COUNTY F.G s PROVIDER ID :..", "-,,_ 4„ `...,1:;',',;;:. 3 :.
PROVIDER NANIEJ MAILING ADDRESS *" CITY STATE ZIP
Andrew, Mark and
1 1559384 22305 WCR 76 Eaton, CO 80615
Susan
2 Baker, Elissa 1552821 2613 15th Ave Ct Greeley, CO 80634
Beaman, Diane and
3 1560953 2808 22nd St Rd Greeley, CO 80634
Chad
4 Brown, Scott and 1524302 301 Hickory Ave Eaton, CO 80615
Robin
5 Buffer, Shawn and 1557395 813 Cameron Drive Windsor, CO 80550
Austin-Buffer, Jody
6 Burden, Craig and 1552261 2203 A Street Greeley, CO 80631
Lea
7 Carter, Jeremy and 1556173 3332 W 35th St Greeley, CO 80634
Susan
8 Clark, Rande and 1561240 901 Greenwood Ct. Fort Lupton, CO
Beverly 80621
9 Corliss, Wade and 1547483 26649 CR 60 1/2 Greeley, CO 80631
Loni
10 Douglas and Kelli 10994 3110 57th Ave Greeley, CO 80634
Roderick
11 Downey, John and 1551054 3826 W 8th Street Greeley CO 80634
Donna
12 Erbacher, Dan and 1546381 3850 Cheyenne Dr Greeley, CO 80634
Hallie
13 Fisher, Matthew and 1532312 5022 W 2nd St Rd Greeley, CO 80634
Claire
14 Fisher, Steve and 1515472 1416 16th Ave Greeley, CO 80631-
Joletta 4535
15 Gariepy, Susan J 1553740 5151 W 29th St#1706 Greeley, CO 80634
16 Gerardy, Jerry and 1530549 3408 Cody Ave Evans, CO 80620
Priscilla
17 Gomez, Oswald and 1588508 7226 Matheson Dr. Fort Collins, CO
Christina 80525
18 Goodman, Bob and 1552796 8134 Louden Circle Windsor, CO 80550
Katie
19 Hays, Stephen Dale 1587489 229 4th Street Fort Lupton, CO
and Chantel 80621
20 Heimer, Sara 1547292 3000 W 19th St Greeley, CO 80634
21 Hendrix, Samuel and 1553157 6606 Tenderfoot Ave Firestone, CO
Shanaine 80504
22 Hernandez, Roberto 1520297 912 Elm Ct Fort Lupton, CO
and Margarita 80621
23 Hoel, Elizabeth 1560688 728 Glen Ayre St Dacono, CO 80514
Holmgren, David and
24 1522699 864 Amber Court Windsor, CO 80550
Dawn
25 Hunt, Olen J and Nina 1503154 224 48th Ave Greeley, CO 80634
19 Weld County SS-23A Addendum
COUNTY FC PROVIDER ID MAILING ADDRESS CITY STATE ZIP
PROVIDER NAME
26 Hymel, Chad and 1540875 1257 Red Mountain Dr Longmont, CO
Tiffany 80501
27 Jackson, Scott and 1536689 425 Hickory Ln Johnstown, CO
Andrea 80534
28 Kinney, Frederick and 1547583 640 E 3rd St Eaton, CO 80615
Margaret
29 Kniss, Kevin and Kelly 1524303 1545 71st Ave Greeley, CO 80634
30 Kohler, Christopher 1556593 10515 Cimmarron St Firestone, CO
and Vance, Michelle 80504
Losc31 Alicia n, Todd and 1528352 1747 68th Ave Greeley, CO 80634
Alicia
32 Maronek, Dennis and 1520627 4860 Eagle Crest Blvd Firestone, CO
Patricia 80504
33 Martinez, Andrew and 1585195 4404 Monte Cimone St Evans, CO 80620
Jeanna
34 Mauk, James and 1537621 3620 Dilley Circle Johnstown, CO
Harriett 80534
35 McCreery, James and 40215 120 Maple Ave Eaton, CO 80615
Tammy
36 McGee, Donna 1539853 1649 31st Ave Greeley, CO 80634
37 Mellmen, Jeffrey and 1547484 352 Laurel Ave Eaton, CO 80615
Letha
38 Mena, David and 1510691 2905 41st Ave Greeley, CO 80634
Marie
39 Middleton, Brian and 1537851 2418 W. 24th St Rd Greeley, CO 80634
Deborah
40 Montez, Joseph and 1582735 3660 W. 25th St#1102 Greeley, CO 80634
Alexis
41 Moore, Earl and 1517579 135 Poplar St Lochbuie, CO
Patricia 80603
42 Parker, Brian and 1538709 3001 50th Ave Greeley, CO 80634
Beryldell
43 Paulsen, Larry and 42268 1939 Homestead Rd Greeley, CO 80634
Helen
44 Pierce, Kris and Larry 1586620 3017 54th Ave Greeley CO 80634
Pluma45 Mike and 35126 PO Box 34 Kersey, CO 80644
Annett Annette
46 Purcella, Denise 1551571 10656 Bald Eagle Circle Firestone, CO
80504
47 Ramos, Julian 37631 2604 49th Ave Greeley, CO 80634
48 Ransome, 1552605 1903 24th Ave Greeley, CO 80634
Christopher and Mary
49 Rasmussen, Dennis 104555 345 Gypsum Lane Johnstown, CO
and Diane 80534
50 Redding, Christopher 1524128 2305 42nd Ave Greeley, CO 80634
and Sonja
51 Reussow, Robert and 103704 4124 W 8th Street Greeley CO 80634
Tracy
52 Ripka, Gary and 1538429 2113 74th Ave Greeley, CO 80634
Jennifer
53 Risner, Larry and 1552270 1104 N 3rd St Johnstown, CO
Vivanco, Katherine 80534
54 Ritter, Thomas and 1554009 10136 Dearfield St Firestone, CO
Deborah 80520
20 Weld County SS-23A Addendum
L COUNTY FC PROVIDER ID MAILING ADDRESS CITY STATE ZIP
PROVIDER NAME
55 Roderick, Douglas 10994 3110 57th Ave Greeley CO 80634
and Kelli
56 Rogers, Jeffrey and 1550689 5221 Bowersox Parkway Firestone, CO
80504
Tami
57 Rothe, Terry and 15169 4115 W 20th St Rd Greeley, CO 80634
Marilyn
58 Rush, Phillip and 1556437 2540 S Flanders Ct. Aurora, CO 80013
Shannon
59 Amy Ss, Corey and 1555552 2026 27th Ave Greeley, CO 80634
60 Schmidt, Donald and 1511343 937 Clydesdale Lane Windsor, CO 80550
Constance
61 Sevestre, Lewis and 1551169 1717 69th Ave Greeley, CO 80634
Maureen
62 Shindle, Danny and 1550177 1606 Fairacres Rd. Greeley, CO 80631
Andrea
Johnstown, CO
63 Skeldum, William 16666 5113 Saguaro Ct
80534
64 Slaughenhaupt, Gary 1544611 30633 CR 78 Eaton, CO 80615
and Grace
65 Steele, Dana and 1551234 324 Fossil Dr. Johnstown, CO
Cassandra 80534
66 Steitz, Daniel and 1546930 1701 Elder Ave Greeley, CO 80631
Natalie
67 Van Den Elzen, Dawn 44282 7219 W 20th St Ln Greeley, CO 80634
Vincent, Jessica and
68 1587461 4910 W 2nd Street Greeley, CO 80654
Ryan
69 Wade, Michael and 1554152 1016 Cottonwood Dr Windsor, CO 80550
Jodyne
70 Walker, Kurt and 1546248 519 Trout Creek Ct Windsor, CO
Jennifer 80550-3194
White, Richard and
71 1545830 3109 W 13th St Greeley, CO 80634
Melissa
72 Willem, Melody D and 1540372 219 N 4th St LaSalle, CO 80645
Lee, Kimberly
21 Weld County SS-23A Addendum
Attachment III
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between «CPA_NAME» 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 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#«FACILITY_ID». 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.
22 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.
E. 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.
23 Weld County S5-23A 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:
24 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
WORKER COMPLETING ASSESSMENT HH# 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 O1)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?
0 Basic Maint.)No participation required O1)Once a month ❑1'/:)Two times month
02)Three times a month ❑2''/)Once a week 03)Two times a week
❑3'/:)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
0 Basic Maint.)No educational requirements 01)Less than a ''/x hour per day ❑1'/:) '/:hour a day
02) 1 hour a day ❑2 '/n) 1'4-2 hours per day 03)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 ❑1) Less than 5 hours per week ❑1'/) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑ 3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding
bathing,grooming,physical, and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week 01)3 to 4 hours per week ❑1'%)5 to 7 hours per week
02)8 to 10 hours per week ❑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.)
O1)Face-to-face contact one time per month with child and minimal crisis intervention.
O 11/2)Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention,
❑2%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
O 0)Not needed or provided by another source(i.e. Medicaid) DI)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
25 Weld County SS-23A Addendur
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
"(xt' Rating of Conditions' v {
1 ttr ::::'1::t 4:k.' (Check one box for each category) l� . {ra4.v{•t
y ' Y 4 5 r,, PP.
blry
n
[ � • �` +� $ '';,.:•;.-',
� 5-kM t'*i'1 t +rw .t.,"-,, 4e1 4..
11;5:1''t. xn o&e Mst = §h/' meats:
Assessment Areas '•kn„ None Milda vNdd/ModeYote. Modepa�e Modem t¢h RS Rig hJSevere �� s
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
Stealing
❑ ❑ 0 0 0 0 0
Self-injurious Behavior
❑ ❑ 0 0 0 0 0
Substance Abuse
El ❑ 0 0 0 0 0
Presence of Psychiatric
Symptoms/Conditions 0 0 0 0 0 0 0
Enuresis/Encopresis
❑ ❑ 0 0 0 0 0
Runaway
❑ ❑ 0 0 0 ❑ ❑
Sexual Offenses
❑ ❑ 0 0 0 0 0
26 Weld County SS-23A Addendun
(Exhibit B)
WELD COUNTY DHS
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
PFh , Rating of Conditions -t : ry
(Check one box for each categor):) a 4r
Assessor ntAreas None Mild ild/Mod rate. 'Moderate Moderate/Hteh t Hteli a Comments
'^ ' -Mt �4" a ,v l ore .- r ' i �
:
0 1• 11/2'r=.. 2 2 1/2 f. ,, 3 3'1/2
Inappropriate Sexual
Behavior ❑ ❑ ❑ 0 ❑ ❑ ❑
Disruptive Behavior
❑ 0 ❑ ❑ ❑ 0 ❑
Delinquent Behavior
❑ ❑ 0 ❑ ❑ ❑ ❑
Depressive-like
Behavior ❑ ❑ ❑ ❑ 0 ❑ ❑
Medical Needs
(If condition is rated"severe", O ❑ 0 ❑ ❑ ❑ ❑
please complete the Medically
fragile NBC)
Emancipation
❑ ❑ ❑ 0 0 ❑ ❑
Eating Problems
❑ ❑ ❑ ❑ ❑ 0 0
Boundary Issues
❑ ❑ ❑ 0 0 ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑ ❑ ❑ ❑
Involvement with
Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
27 Weld County SS-23A Addendun
(check level of need) O 0 Di ❑ 1'/z ❑2 ❑ 2'h ❑ 3 ❑ 31/4
(Exhibit C)
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
RECIOMMENDED yr ' ''� MEDICA +�*+
LEOVEL' -9siwo' .s RECOMMENDED AGENCY RATE '`a TH�,e,RATE••a
j PROVIDER RATE' + tiu w7,r^� f#sit .A4NDUM
SER CE
. ..r°,: P1 -PS � "c.",". -"'.*'.��~M:FAt - o-+'+rs'.y ,.m.. -:s T7'
.Level , Rate Case". ai agement Therapy! a "Level "
f). s
�,r , i�Y„ . t�(Admin.MamtJ�:�,s;- � *;.�-..(Admin.Services) '� . .
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 w Level 0...$0
Maint.
Age 15-21...$19.27 ', (None)
($586) involvement, one face-to-face visit another source, i.e.mental health. `t
+$.66 Respite Care
($20) F‘, with child per month.
$19.73 Level 1 $8.22 day/$250 mo Level 1.. $4.93/$150 mo
1 +$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy,
one face-to-face visit per month with Level 1 ...$2.99
($20.39 day/$620 mo) child, up to 4 hours/month.
2-3 contacts per month
$23.01 '
1 1/2 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo : ;
($23.67 day/$720 mo)
$26.30 s Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo
2 +$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy, Level 2..$4.47
two face-to-face visits with child, 5-8 hours a month with 4 hours of
($26.96 day/$820 mo)
2-3 contacts per month group therapy.
$29.59 '"a' S.
2 1/2 +$.66 Respite Care ' Level 2 1/2 $13.15 day/$400 mo k
($30.25 day/$920 mo) +
₹,
$32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo r
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly s
multiple sessions,can include
3 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,
multiple services. for 9-12 hours/monthly.
$36.16
3 1/2 +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo
($36.82 day/$1,120 mo)
$39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
+$.66 Respite Care 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) k;
child and provider and 2-3 face-to-face for 9-12 hours/monthly.
,, contacts er week minimum.
';',.:z..'.:-
is ..' :- 'ar'.,, 5_a`sra.>."' 7t �v.a: ..-.i, 4..d k P..u.i-.:,..- ,. 2 - ".,..w.,.... -_ '''.._,.1..,_
Assess/
Emergency . $30.25 day/$920 mo $13.15 day/$400 mo
Level (Includes Respite)
Rate
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
28 Weld County SS-23A Addendur
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:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «CPA_NAME»
OF HUMAN SERVICES «MAILING_ADDRESS»
«CITY STATE_ZIP»
By: By:
Director
r �r° "�". "71'''
- t,,,i, ::t.
FACILITY
CPA PROVIDER NAME -- MAILING ADDRESS 4. -CITY STATE ZIP
• 1 Adoption Alliance 71259 2121 S. Oneda St, Suite 420 Denver, CO 80224 j
2 Adoption Options 45078 13900 E Harvard Ave, Suite Aurora, CO 80014 i 200• 3 IAriel Child Placement Agency I 90205 I 4251 Kipling St, Unit 500 1 Wheat Ridge, CO 80033-2899
Colorado Springs, CO 80907-
4 Bethany Christian Services 45514 4820 Rusina Rd, Suite C ,
8127 ,
5 Bridges Inc. 1980 1225 N Mal Sstreet, Suite Pueblo, CO 81003
16 ICommonworks, DBA Synthesis 104085 5310 Ward Rd, Suite G-01 Arvada, CO 80002
7 (Frontier Family Services 38041 I 1290 Boston Ave Longmont, CO 80501-5810
8 IHope & Home 29867 11925 Dominion Way, Ste 200 Colorado Springs, CO 80918
9 (Hope Family Services 42942 I 1610 29th Ave Place#100 Greeley, CO 80634
10llmagine 21369 1400 Dixon Ave Lafayette, CO 80026
.11(Journeys Inc. 1525317 I 503 N Main Street Pueblo, CO 81003
Colorado Springs, CO 80910-
'12 Kids Crossing 79752 1440 E Fountain Blvd
3502
T1Kids Resource Network of Colorado
3 1508602 3715 Parkmoor Village Dr Colorado Springs, CO 80917
Springs
;14'Lost and Found Inc. I 57351 I 6700 44th Ave I Wheatridge, CO 80033
15lllLutheran Family Services of Colorado I 45080 I 2032 Lowe Street, Suite 200 I_ Fort Collins, CO 80525
!l6IMaple Star Colorado 90967 2250 S Oneida Street, Suite1
Denver, CO 80224-2557
117 ISavio House I 37330 1 325 King Street I Denver, CO 80219
'18jSmith Agency Inc. I 44882 I 7169 S Liverpool St f Centennial, CO 80016
-19ISpecial Kids Special Families I 43184 r 424 W Pikes Peak Ave I Colorado Springs, CO 80905
,20'Youth Ventures of Colorado I 1554849 I 4785 Granby Cir I Colorado Springs, CO 80919 !
Attachment IV
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Group Home/Group Center Care Services (the
"Agreement") between «CENTER_NAME» 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 , 2011, are added to the referenced Agreement.
Except as modified hereby, all terms of the Agreement remain unchanged.
1. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in
this Agreement at a rate of$«PROVIDER_RATE», per day for children placed within the Group
Home/Group Center identified as Provider ID #«FACILITY_ID». 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.
2. 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.
3. 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.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by
the child, will be furnished under this contract for facilities that provide sex offender treatment.
5. 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.
6. Add Paragraph 8 to Section I. The services purchased under this Agreement for Group Home/Center
services may include, but are not limited to: Basic 24-hour care and child maintenance (food, shelter,
clothing, educational supplies and allowance), direct child care, transportation, administrative overhead,
support overhead, service delivery staff, which may include but are not limited to: Parent training for
teens, independent living training, and mentor/advocate services.
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.
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
Human Services to shorten the duration of placement.
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.
10. 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.
11. 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.
12. 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 Human
Services Policy and Procedure Manual.
13. 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.
14. 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.
15. 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 Human Services and the Contractor, or by Human Services as a debt to
Human Services or otherwise as provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event that
the Contractor learns of any actual litigation in which it is a party defendant 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.
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:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «CENTER_NAME»
OF HUMAN SERVICES «MAILING_ADDRESS»
«CITY STATE ZIP»
By: By:
Director
r K, ,... a oAC LITY
GROUP MAILING u CITY-STATE PROVIDER FACILITY FACILITY_ITY ACILIA CITY$TATE
CENTER: ADDDtES , .ZIP * ,-RATE- IDS,,`,', NAME ADDRESS
NAM ,:f.,/,.., 5,. : " _:4Qt* • , ,W,, ZIP
Colorado Colorado
3 A Kidz Hope 1401 W A Kidz Hope 116 S 14th
1 Homes Inc. Colorado Ave Springs, CO $89.13 1531612 Annex Street Spring, CO
80904 80904
A Kidz Hope 1401 W Colorado 1401 W Colorado
2 Springs, CO $95.00 1531611 A Kidz Hope Colorado Springs, CO
• Homes Inc. Colorado Ave
80904 Ave 80904
3 Evergreen 1436 Hilltop Dr. Longmont, CO $102.00 61317 Evergreen 1436 Hilltop Longmont, CO
Group Center 8O5O1 Group Center Dr 80501
1 14142 Denver Colorado
iI Griffith Center Lakewood, CO $115.00 1543863 Prospect Youth 28 Farragut
West Pkwy, Springs, CO
4 for Children Suite 225 8O4O1 Home Ave 80909
14142 Denver
5 Griffith Center West Pkwy, Lakewood, CO $11500 1531601 Meridian Youth 11875 Smith Peyton, CO
for Children Suite 225 80401 . Ranch LN 80831
6 Heritage PO Box 195 Louisville, CO $100.00 1520452 Heritage 333 East Louisville, CO
House 80027 House Street 80027
Colorado 12799
1440E Second Aurora, CO
7 Kids Crossing Fountain Blvd Springs, CO $95.34 1552984 Chance Exposition 80012
80033 Dr.
Colorado
8 Kids Crossing 1440E Springs, CO $95.34 1536449 • Family First 4648 Denver, CO
Fountain Blvd 80033 Auckland Ct 80239
Colorado
9 Kids Crossing 1440E Springs, CO 95.34 1551132 Helping Hands 21622E Centennial,
[Forlvd 80033 Group Home Alamo Place CO 80015
Maple Star 2785 Speer Denver, CO Christi Beach 6233 Xavier Arvada, CO
'10 Colorado Blvd, Suite 340 80211 $86.00 13416 Group Home Street 80003
11 Savio House 325 King Street Denver, CO $106.96 1517239 The Lampkin 2836 Vine Denver, CO
80219 Home 80205
Denver, CO JCS Jorney 705 S Harlan Lakewood, CO.
I12 Savio House 325 King Street $106.96 1548844
80219 For Girls Street 80226-4719
3297
13 Savio House 325 King Street Denver, CO $106.96 1548445 Carr Group Jasmine Denver, CO
80219 Center for Girls 80207
Street
14 Savio House 325 King Street Denver, CO $81 24 5628 Wilson Group 15005 Denver, CO
80219 Home Maxwell PI 80239
Smith Agency 7169 S Centennial, 4195 S Aurora, CO
15 DBA Serenity $147.77 1540493 Serenity IX
Liverpool St CO 80016 Pagosa Ct 80013 :.
IX
Youth 4785 Granby Colorado 20765 Oasis Peyton, CO
16 Ventures of Cir. Springs, CO $91.60 2611 F.I.C.O.S.A. Ave 80831
Colorado 80919
Youth 4785 Granby Colorado 2610 Colorado •
17 Ventures of Springs, CO $91.60 1530211 Youth Alliance Montebello Springs, CO
Colorado Cir. 80919 Dr.W 80918
I
1111. Youth Colorado Colorado
18 Ventures of 4785 Granby Springs, CO $91.60 1545224 Ricky's House 4415E San Springs, CO
Cri . Miguel
Colorado 80919 80915
GROUP - f� ' x f� ,- ''".''.�. -4:_ �--
'` ` FACILITY.
CENTER', t t MAILING CITY STATE PROV ER FACILITY FACILITY FAc LITY CITY STATE'
-NAME AbDRESS;3 ZIP. r RATE ID NAME ADDRESS ;.ZIP-1.7;,7;;,.
19 Youth Colorado Colorado
Ventures of 4785 Granby Springs, CO $91.60 15801 Future Bound 3101 Palmer Springs, CO
Colorado Cir. 80919 Park Blvd 80909
3705 Dixon
Colorado ,
20 Youth Colorado 1549764 Open Arms Way Springs, CO '
Ventures of 4785 Granby Springs, CO 80909
Colorado Cir. 80919 $91.60
2113 Colorado
21 Youth Colorado 1555972 Hoder Waller Patrician Springs, CO
Ventures of 4785 Granby Springs, CO Group Home Way 80909
Colorado Cir. 80919 $91'60 1
Youth 4785 Granby Colorado 3590 LaMar Colorado
22 Ventures of Springs, CO $91.60 1534441 LaMar Place PI Springs, CO
Colorado Cri . 80919 80911
Attachment V
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Residential Child Care Facility Services (the
"Agreement") between «RCCF_NAME» 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 the Agreement remain unchanged.
1. County agrees to purchase and Contractor, identified as Provider ID#«FACILITY_ID», agrees to
provide:
A. Child Maintenance, Administrative Maintenance and Services, which are listed in this
Agreement at a rate of S«PROVIDER_RATE»per day for children placed within the
Residential Child Care Facility unless the child is eligible for the CHRP program. If the child is
deemed CHRP eligible, County agrees to pay the federal SSI rate to Contractor and all other
service costs will be billable under the CHRP program.
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.
2. Section I, Paragraph 1. _County considers the agreed upon rate, outlined in the Weld County Addendum
to this contract, to be all inclusive and shall not pay for additional treatment fees; i.e. Drug/Alcohol and
Sex Offender services.
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.
Reimbursement rates for bed hold days may not exceed the state standard rate for administrative
maintenance and administrative services or may be a reduced rate that is mutually agreed upon.
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. The services purchased under this Agreement as Child Maintenance,
Administrative Maintenance and Services for Residential Child Care Facilities include, but are not
limited to: Food, shelter, clothing, personal needs and allowance, administration, administrative
overhead, support staff, support overhead, sleep-over staff, direct child care, transportation, therapeutic
recreation, service delivery staff, parent training for teens, independent living training, mentor/advocate,
supervised visitation and all other services as outlined in the Contractor's scope of service attached as
Exhibit A or the Child Specific Addendum. The anticipated minimum percentage for each item is as
follows and will be subject to County monitoring as outlined in Section VI of this contract:
A. Food, including meals and snacks (25%);
B. Clothing (3%);
C. Shelter, including utilities and use of household furnishing and equipment and daily supervision,
including those activities that a parent would normally carry out to assure protection, emotional
support and care of the child (30%);
D. Personal items and grooming care for the child, such as toothpaste, toothbrushes, soap, combs,
haircuts, and other essentials (2%);
E. Other/miscellaneous items considered usual in the care and supervision of the child, include, but
are not limited to, transportation, recreation and overhead (40%)
6. Add Paragraph 8 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 9 to Section I. Any additional costs for specialized services, which include, but are not
limited to; polygraph tests, plethysmographs, and urinalysis screens, that is not provided within the
vendor rate or attached Scope of Service, will need be negotiated and 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 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. Provider 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
Human 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 will 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 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 Human 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.
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 Human 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.
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:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «RCCF_NAME»
OF HUMAN SERVICES «MAILING_ADDRESS»
«CITY_STATE_ZIP»
By: By:
Director
ITY
ROVI F ` M TILLING ITY STATE PROVIDER FACILITY; `FACILITY~ ' , FA 1 �1TY rFACI TAT
��'!�! .� dITY STATE,-PROVIDER ADDRESS`'' 4' 'ZIP RATE ID '�= 'F' NAME ;_` . ADDRESS :r-,
NAME ZIP
S
Roundup One da0 Denver, $147.77 45105
CO, Roundup 1345 St Paul Denver, CO,
1
Fellowship 201' Suite 80224 Fellowship I St 80206
2250 S Colorado
2 Roundup Oneida, Suite Denver, CO, $147.77 45211 Roundup 4441 Fortune Springs, CO,
Fellowship 201 80224 Fellowship III Cir 80917
2250 S Colorado
3 Roundup Oneida, Suite Denver, CO, 45212 Roundup 1234 N Springs, CO
Fellowship 21 $147.77ip V Meade St g0909TJ
7169 S. Centennial, Serenity II 14759 E. Aurora, CO
4 Smith Agency Liverpool St. CO 80016 $147.77 6566 Childress Pacific PI 80014
I Home
Attachment Vi
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Specialized Group Home Care Services (the
"Agreement") between <CENTER_NAME» 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 the Agreement remain unchanged.
1. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in
this Agreement at a rate of$50.04, per day for children placed within the Group Home identified as
Provider ID#«FACILITY_ID». 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.
2. 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.
3. 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.
4. Add Paragraph 6 to Section I. The services purchased under this Agreement for Group Home services
may include, but are not limited to: Basic 24-hour care and child maintenance (food, shelter, clothing,
educational supplies and allowance), direct child care, transportation, administrative overhead, support
overhead, service delivery staff, which may include but are not limited to: Parent training for teens,
independent living training, and mentor/advocate services.
5. 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.
6. 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.
7. Add Paragraph 15 to Section IV. Agree to cooperate with any vendors hired by Weld County
Department of Human Services to shorten the duration of placement.
8. 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 will be placed in the group home placement binder.
9. Add Paragraph 17 to Section IV. Meet with the Department of Human Services supervisor for a
minimum of two hours weekly (7.709.21).
10. Add Paragraph 18 to Section IV. Work collaboratively with Department staff, mental health
professionals, GAL's, CASA volunteers, and other service providers in arranging times that the
Contractor's home is open to professional visits. Contractor also understands that the County
Department Caseworker and GAL have the right to make unannounced home visits to check the child's
safety, needs, and environment.
11. Add Paragraph 19 to Section IV. Ensure that hired staff are; completing training specific to the children
they service, and are current on all trainings and other requirements as mandated by CDHS Volume 7
Policy and Procedure Manual section 7.700.
12. Add Paragraph 20 to Section IV. Accompany key professionals to school conferences, IEP meetings,
school-related staffings, Foster Care Reviews and Court Hearings.
13. Add Paragraph 21 to Section IV. Immediately report any significant issue, regarding the youth, to the
youth's assigned caseworker. Issues may be medical, behavioral, legal/criminal, or educational in
nature. If a youth becomes a threat to him/herself or others, appropriate "critical incident"
documentation must be prepared by the specialized group home parent according to State guidelines
(7.701.52), in addition to notification to the caseworker. While specialized group home parent attempts
to maintain the youth at the group home level of care, the specialized group home parent will be familiar
with Weld County's continuum of care and understand when a child needs to be forwarded or regressed
through the continuum.
14. Add Paragraph 22 to Section IV. Immediately report to the County Department and/or local law
enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
15. Add Paragraph 23 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.
16. 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.
17. 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.
18. 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 Human Services and the Contractor, or by Human Services as a debt to
Human Services or otherwise as provided by law.
19. Add Paragraph 10 to Section VI. The Contractor shall promptly notify Human Services in the event
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.
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:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «CENTER_NAME»
OF HUMAN SERVICES «MAILING_ADDRESS»
«CITY_STATE_ZIP»
By: By:
Director
By:
SPECIALIZED GROUP HOME FACILITY FACILITY FACILITYt. FA ILITY CITY
FACILITY NAME
PROVIDER RATE ID ADDRESS ,. STATE ZIP, i,,
1 C & M Group Home r $50.04 �I 9875 TC & M Group Home 1920 81st Ave Greeley CO 80634
:2 Earl and Cindy Almond $50.04 1 61603 Almond Group Home 1937 Ave Chestnut Greeley CO 80631
3 Marie Alirez Group Home $50.04 70335 Marie Alirez Group 1405 26th Street Greeley CO 80631
Home i
4 Michael Alirez Group Home $50.04 54150 Michael Alirez Group 1709 37th Ave Greeley CO 80634 •
Home
5 Michael and Alecia Cowper $50.04 1526756 Michael Cowper 509 N Sholdt Dr Platteville, CO
Group Home 80651
Attachment VII
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Residential Child Care Facility Services (the
"Agreement") between «RCCF_NAME» and Weld County Department of Human Services
for the period from
July 1, 2010 through June 30, 2011.
The following provisions, made this day of , 2010, are added to the referenced Agreement.
Except as modified hereby, all terms of the Agreement remain unchanged.
1. County agrees to purchase and Contractor, identified as Provider ID#«FACILITY_ID», agrees to
provide:
A. Child Maintenance, Administrative Maintenance and Services, which are listed in this
Agreement at a rate of$«RCCF_RATE» per day for children placed within the Residential
Child Care Facility.
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.
2. Section I, Paragraph 1. County considers the agreed upon rate, outlined in the Weld County Addendum
to this contract, to be all inclusive and shall not pay for additional treatment fees; i.e. Drug/Alcohol and
Sex Offender services
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.
Reimbursement rates for bed hold days may not exceed the state standard rate for administrative
maintenance and administrative services or may be a reduced rate that is mutually agreed upon.
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. The services purchased under this Agreement as Child Maintenance,
Administrative Maintenance and Services for Residential Child Care Facilities include, but are not
limited to: Food, shelter, clothing, personal needs and allowance, administration, administrative
overhead, support staff, support overhead, sleep-over staff, direct child care, transportation, therapeutic
recreation, service delivery staff, parent training for teens, independent living training, mentor/advocate,
supervised visitation and all other services as outlined in the Contractor's scope of service attached as
Exhibit A or the Child Specific Addendum. The anticipated minimum percentage for each item is as
follows and will be subject to County monitoring as outlined in Section VI of this contract:
A. Food, including meals and snacks (25%);
B. Clothing (3%);
C. Shelter, including utilities and use of household furnishing and equipment and daily supervision,
including those activities that a parent would normally carry out to assure protection, emotional
support and care of the child (30%);
D. Personal items and grooming care for the child, such as toothpaste, toothbrushes, soap, combs,
haircuts, and other essentials (2%);
E. Other/miscellaneous items considered usual in the care and supervision of the child, include, but
are not limited to, transportation, recreation and overhead (40%)
6. Add Paragraph 7 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 8 to Section I. Any additional costs for specialized services, which include, but are not
limited to; polygraph tests, plethysmographs, and urinalysis screens, that is not provided within the
vendor rate or attached Scope of Service, will need be negotiated and 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 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. Provider 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
Human 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 will 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 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 Human 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.
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 Human 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.
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:
Deputy Clerk to the Board Chair Signature
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT «RCCF_NAME»
OF HUMAN SERVICES «MAILING_ADDRESS»
«CITY STATE ZIP»
By: By:
Director
RCCF MAILING_ CITY STATE ,RCCF FACILITY `r NA ��►�CILITY ` �`'
FAGIUTY
FAC ITY NAME kDORESS Cly STATE
PROVIDER,.. `ADDRESS ZIP RATE ID _. ,x.t
f • ZIP
•
3080 Boulder, CO Attention Homes 3682 Chase Boulder CO
!1 Attention Homes Broadway, $139.00 11679
Suite C
2 1ttention Homes BroadBway, Boulder, CO Attention Homes 3080 Boulder CO
80304
80304 $135.00 7496 —Broadway Broadway,
Suite C Suite C
Cathedral Cathedral
Laramie,WY Laramie WY
3 Homes for PO Box 520 82073 $522.00 17961 Homes for PO Box 520 82073
Children Children
Dale House Colorado Colorado
Dale House
4 Project 7 W Dale St Springs, CO $109.71 1502911 Project 24 E Dale St Springs CO
80903 80903
Mount Saint 4159 Lowel Denver, CO Aspen House At 4157 Lowell Denver CO
15 Vincent Blvd 80211 $138.88 1541575 Mount Saint Blvd 80211
Vincent
PO Box Memphis, TN 7410 Memphis Bartlett TN
;6 Youth Villages 341154 38184-1154 $390.00 1511780 Youth Villages Arlington Rd 38135
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