HomeMy WebLinkAbout20091219.tiffRESOLUTION
RE: APPROVE STANDARD FORMS FOR AGREEMENT TO PURCHASE OUT -OF -HOME
PLACEMENT SERVICES AND ADDENDUMS THERETO BETWEEN THE WELD
COUNTY DEPARTMENT OF HUMAN SERVICES AND VARIOUS PROVIDERS, AND
RATIFY CERTAIN AGREEMENTS PREVIOUSLY SIGNED BY THE CHAIR
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, the Board has been presented with forms of an Agreement to Purchase
Out -of -Home Placement Services and Addendums thereto, 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, and to ratify any such
agreements which were previously executed by the Director of Human Services without signature
by the Chair.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, ex -officio Board of Social Services, that the forms of the Agreement to Purchase
Out -of -Home Placement Services and Addendums thereto, 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.
BE IT FURTHER RESOLVED by the Board that any such agreements which were
previously executed by the Director of Human Services without signature by the Chair be, and
hereby are, ratified.
2009-1219
H R0080
RE: APPROVE STANDARD FORMS FOR AGREEMENT TO PURCHASE OUT -OF -HOME
PLACEMENT SERVICES AND ADDENDUMS THERETO 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 27th day of May, A.D., 2009.
ATTEST:
Weld County Clerk to the B
BY
Deputy" erk to the Board
APPROVED AS TO FORM:
Sean P. Conway
Apliii4)&a9 ! A CJ
15my A rney
Date of signature. 69/67
BOAt7D OF C• - Y COMMISSIONERS
W LD�OOU.. 'ADO
c
aarber
ara Kirkmeyer
David E. Long
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2009-1219
H R0080
AGREEMENT TO PURCHASE
OUT -OF -HOME PLACEMENT SERVICES
SS23A
❑ CHILD PLACEMENT AGENCY SERVICES (CPA)
❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP)
❑ GROUP HOME/GROUP CENTER CARE
❑ INDEPENDENT LIVING
❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF)
❑ RESIDENTIAL CHILD CARE FACILITY (RCCF)
❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM
❑ SHELTER CARE
❑ SUBSIDIZED ADOPTION
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER -CARE (RCCF)
❑ OTHER (DESCRIBE):
THIS AGREEMENT, made this day of between the Weld
County Department of Social/Human Services hereinafter called "County" and
«CONTRACTOR_NAME», «MAILING_ADDRESS», «CITY_STATE_ZIP»,
hereinafter called "Contractor." THIS AGREEMENT, shall include all children placed
by the Weld County Department of Social/Human Services and
«CONTRACTOR NAME».
A child specific addendum, identifying individual service needs, must be completed and
attached to supplement this agreement for each child being served by the facility. If this
is a CPA placement, the child specific addendum should also address how administrative
services will be provided in the event the child is placed for adoption in a foster home
supervised by the CPA.
WHEREAS, the Colorado State Department of Human Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of
individuals through its agents, County Departments of Social/Human Services, and
WHEREAS, the County is authorized to purchase certain services for eligible children
under State Department rules, and
WHEREAS, the County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child
Care Facility, certified Psychiatric Residential Treatment Facility, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
SS -23A revised 2/09
I
NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings
the County and the Contractor agree as follows:
1. This Agreement shall be in force from the date of the agreement, July 1,
2009, until the end of the Colorado fiscal year, June 30, 2010. Any child
may be removed from the facility prior to the end of the fiscal year by the
county department.
2. This Agreement may be renewed only by entering into a new written
Agreement such as this Agreement signed by the authorized
representatives of the parties. Except as otherwise provided above, either
party shall have the right to terminate this contract by giving the other
party thirty (30) days notice by registered mail, return receipt requested. If
notice is so given, this contract shall terminate on the expiration of the
thirty (30) days or until the eligible child(ren) can be placed elsewhere,
whichever occurs first, and the liability of the parties hereunder for further
performance of the terms of this Agreement shall thereupon cease, but the
parties shall not be released from the duty to perform their obligations up
to the date of termination.
3. This Agreement is in lieu of and supersedes all prior agreements between
the parties hereto and relating to the care and services herein described.
SECTION I - DESCRIPTION OF SERVICES TO BE PURCHASED
1. The total rate of payment for care and services under this Agreement shall not exceed:
the established rate for the PRTF; for CPA placements, the negotiated rate or the
approved vendor rate; for 1RCCF placements, the established Fee -for -Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements the negotiated rate
or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal
rate. The total rate of payment for care and services for other service types will be as
negotiated between the County and the Contractor. Medicaid rules shall govern activities
to be covered in the daily rate paid to PRTFs.
The amount paid for purchased care and services for less than a full month will be based
upon the daily rate.
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1, F (12 CCR 2509-5).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
SS -23A revised 2/09
2
County. The County has responsibility for the decision to return the child to the facility,
with input from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the Family Service Plan / Individual Plan of
Care.
5. Any transportation costs to be incurred on behalf of a child in placement, which are to
be borne by persons, or agencies, which are not a party to this contract, shall be specified
in the treatment/service plan, and those persons shall acknowledge their responsibility by
signing the treatment/service plan.
SECTION II - LEGAL STATUS AND AUTHORIZATIONS
1. Such permission as is held by the County is hereby granted to the Contractor to
authorize routine or emergency medical and dental treatment except that:
a. Medical or dental care shall be provided by personnel duly licensed by law as required
by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery,
ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not
included in the monthly rate. The cost of any items not covered by Medicaid will be
negotiated between County and Contractor. Medicaid rules shall govern activities to be
covered in the daily rate paid to PRTFs.
2. County and Contractor shall insure that the child(ren) is enrolled in the Early and
Periodic Screening, Diagnosis and Treatment Program.
3. It is agreed and permission is granted for the child(ren) to participate in planned
recreational and social activities of Contractor, including supervised off grounds
excursions and extended trips within the State, provided that Contractor has written
permission from County and legal guardian for any trips out of Colorado for any reason
and any planned absence from the facility of over seven (7) days within a consecutive 30 -
day period. Such written permission may be in the treatment/service plan. Further,
Contractor and County will also secure, where possible, permission from parents or
guardians of the child placed with the Contractor. Any planned absence of more than 24
hours for children placed in a PRTF is not Medicaid reimbursable.
4. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status which comes to their attention.
SS -23A revised 2/09
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SECTION III - REASONS FOR REFERRAL, TREATMENT PLAN, AND
PROGRESS REPORTS
1. County and Contractor agree and understand that the reasons for referral, which
necessitate purchasing services for children are specified in the attached child specific
addendum and Family Services Plan. Any other relevant information concerning these
children that does not necessitate purchasing services is also included in the addendum.
2. County and Contractor shall develop an initial plan that addresses the immediate
and/or emergency needs of the child within 72 hours of admission for children in
TRCCFs, RCCFs or group homes except PRTF. County and Contractor shall formulate
an initial individual plan of care within 14 calendar days after admission for children in
TRCCFs, RCCFs or group homes except PRTF. The placement date is that date noted in
the attached child specific addendum included with this contract. The Child's Family
Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities.
Modifications to this plan shall be agreed to in writing on the plan or as a supplemental
document.
3. County and Contractor shall formulate an initial individual plan of care for children in
PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care
must be completed by the multidisciplinary team within 14 calendar days from the
placement date. The placement date is that date noted in the attached child specific
addendum included with this contract. Modifications to this plan shall be agreed to in
writing on the plan or as a supplemental document.
4. The individual plan of care shall be goal oriented and time -limited and shall:
a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with
clinical and other needs including the child's presenting problems, physical
health, emotional status, behavior, support system in the community, available
resources, and discharge plan.
b. Include specific goals and measurable objectives, expected dates of
achievement, specific discharge and transitional/after-care and follow up services
criteria to be met for termination of treatment.
c. Specify the type, frequency, and duration of clinical therapy services,
rehabilitation services, medication management, emergency services, initial
assessment, documented treatment modifications, and other services determined
to be necessary to meet the child's specific goals.
d. Specify that all TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
SS -23A revised 2/09
4
e. Identify the provision of, or the referral for, services other than TRCCF services
and shall document any court ordered treatment including identifying the agency
responsible for providing the court ordered treatment.
f. Anticipated living arrangement for the child at the date of discharge;
g. Anticipated educational arrangement for the child at the time of discharge;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, RCCFs and other contractor types
other than PRTF, shall conduct a monthly review of each plan to evaluate whether the
short-term and long-term goals have been achieved or not achieved. These parties shall
provide the County with written reports which address changes to the child's physical
condition, psychological and social functioning, changes in the child's family situation,
educational progress, significant incidents or disciplinary actions, and progress made to
achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence
reports to be received by the County 15 calendar days prior to judicial or administrative
hearings or reviews when provided with 30 calendar days advance notice of such dates by
County.
6. Every 14 days, PRTFs shall provide the County with written reports which address
changes to the child's physical condition, psychological and social functioning, changes
in the child's family situation, educational progress, significant incidents or disciplinary
actions, and progress made to achieve goals specified in the treatment plan.
SECTION IV - CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Human Services, the Colorado Department of Health Care Policy and Financing (if
appropriate), the State of Colorado and any applicable federal laws and regulations, as
such, which may be amended from time to time, and shall be binding on Contractor and
control any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law and rule.
3. Not charge any fees to children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub -contract
without the express written approval of the Director of the County Department or his/her
appointed designee.
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5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act
of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security
Act of 1975 as revised, and provide confidentiality of information concerning the child in
compliance with the Health Insurance Portability and Accountability Act (HIPAA).
6. Maintain during the term of this Agreement a liability insurance policy of at least
$25,000 for CPAs and $400,000 for PRTFs, TRCCFs, and RCCFs for property damage
liability, $150,000 for injury and/or damage to any one person, and $600,000 for total
injuries arising from any one accident.
7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two
(2) months gross receipts, whichever is greater, covering the activities of any of its
officers, agents or employees responsible for the implementation and/or administration of
this contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
8. Indemnify County, Colorado Department of Human Services, Colorado Department of
Health Care Policy & Financing, and the State of Colorado against any and loss against
all claims and actions based upon or arising out of damage or injury, including death, to
persons or property caused or sustained in connection with the performance of this
contract or by conditions created thereby, or based upon any violations of any statute,
ordinance, or regulation and the defense of any such claims or actions.
Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county
departments.
9. In regards to University of Colorado contractors only, the contractor shall be
responsible for its own wrongful or negligent acts or omissions or those of its officers,
agents, or employees while performing their professional duties to the full extent allowed
by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or
waiver of the application of the Colorado Governmental Immunity Act set forth in §24-
10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the
University of Colorado, its employees or agents under this Agreement.
10. Maintain service program records, fiscal records, documentation and other records,
which will sufficiently and properly reflect all direct and indirect costs of any nature
incurred in the performance of this Agreement. The above shall be subject at all
reasonable times to inspection, review or audit by federal, Colorado Department of
Human Services, Colorado Department of Health Care Policy & Financing, or county
personnel, and other persons authorized in writing by the Executive Director of the
Colorado Department of Human Services.
11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the
initial home study, the SAFE study update, annual certification updates and related
materials when requested by the County within fourteen working days of the request. At
all other times the Contractor shall make home studies and related materials available to
SS -23A revised 2/09
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the County for review, at a location agreed upon by the County and the Contractor,
during regular business hours.
12. Bill the County for services rendered, using the required form. This form is to be
mailed to the County by the last day of the month of care. Billings for PRTFs shall be
made to the MMIS System only. Billings for TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, CPAs and other contractor
types shall be made to the County only. Contractor will not be paid by the county when
billing is not received by the County within 30 calendar days following the billing due
date.
13. Attend and participate in Administrative Reviews for children in placement with the
Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall
encourage children over the age of twelve to attend their Administrative Reviews.
Participation may be in person or by teleconference.
14. The Contractor shall pay the foster parent the amount agreed upon with the county as
the child maintenance or room and board. Any payment to the foster parent in excess of
the child maintenance or room and board amount shall be treated as income to the foster
parent.
SECTION V - COUNTY SHALL:
1. Determine eligibility of the children under this Agreement for placement and medical
coverage. Medicaid rules and regulations shall govern determination of Medicaid
eligibility.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Human Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate when billing is submitted as described in Section IV, Number 10
(above).
4. Abide by all the rules and regulations of the Colorado Department of Human Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. If this agreement covers an initial placement for a child, the Contractor may receive a
clothing allowance in accordance with State Department rules.
6. Monitor children's progress in accordance with the treatment/family services plan and
the requirements of Colorado Department of Human Services rules and provide
consultation to Contractor in relation to the services purchased under this Agreement.
SS -23A revised 2/09
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7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled
review.
8. Involve Contractor in planning for the child and give the Contractor a copy of the
Family Services Plan at time of placement or as soon as completed and when updated or
revised.
9. The County shall seek recovery from the TRCCF, RCCF, CPA or other contractor type
for any non Medicaid payment amounts that have been misused as defined in rules. The
County may withhold subsequent payments to recover any funds misused by the TRCCF,
RCCF, CPA or other contractor type. The County shall seek recovery of any remaining
funds as a debt due the County for the benefit of the state. The TRCCF, RCCF or CPA
may appeal the decision to recover or withhold subsequent payments as defined in rules.
10. The County shall identify the amount agreed upon with the Contractor to be paid to
the foster parent for the child's room and board. Such amount will be the same as shown
in Trails for the child's maintenance.
1 1 . Reimbursement rates that are negotiated between the County and the Contractor shall
be for allowable costs in one or more of four primary components: child maintenance,
administrative services, administrative maintenance, and treatment. Contractor type will
determine which of these four components will be included in the reimbursement rate.
SECTION VI - GENERAL PROVISIONS
I. The Parties to this Agreement intend that the relationship between them, contemplated
by this Agreement is that of employer independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of the County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub -contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing availability
of State of Colorado, county, and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor will be
released from responsibility for loss or damage to such personal items.
4. This Agreement is intended to be applied in conjunction with the child specific
addendum and family services plan as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other amendment
hereto shall have any force or affect whatsoever, unless embodied herein in writing. No
subsequent notation, renewal, addition, deletion, or other amendment hereto shall have
any force or effect unless embodied as a part of this written Agreement. This section shall
55-23A revised 2/09
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not be construed as either prohibiting the periodic amending of the family services plan
or appending a county designed addendum to this agreement.
5. The contract shall permit the State Department to monitor service program, fiscal and
other records sufficiently to assure the purchase of services in this Agreement are carried
out for the benefit of the aforementioned client. Monitoring may occur through review of
program reports, on -site visits where applicable and other contracts as deemed necessary.
The Contractor understands that the State Department may provide consultation to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
A. All reimbursement requests shall be submitted to and approved by the
appropriate County staff. Reimbursement for placement services shall be paid
from the date of admission up to, but not including, the day of discharge.
Furthermore, Medicaid payments for PRTF and CHRP placements are permitted
on the day of discharge in compliance with regulations promulgated by the
Colorado Department of Health Care Policy and Finance. Fee for Service will be
reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to
funds encumbered in this contract and shall also include Medicaid funds for PRTF
and TRCCF therapeutic programs and CHRP placements paid by the Department
of Health Care Policy and Financing. Payment for placement services will not be
provided for clients on "runaway" status unless the County has previously
approved it. Reimbursement requests for therapy costs for clients enrolled in
PRTF, TRCCF, and CHRP programs shall be submitted to the Medicaid Fiscal
Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly
basis.
In the event that a Contractor receives payment for a per diem discharge day,
regardless of funding source, the Contractor shall refund those dollars forthwith.
B. The purpose of these requirements is to provide minimum assurance that the
Contractor has adequate accounting and budgeting information available to allow
management to maintain a financially viable enterprise and to demonstrate
financial accountability to the county departments of human/social services and
Colorado Department of Human Services for the use of public funds.
(1) The Contractor must have in place a double entry accounting system and all
financial transactions must be posted to this system. Financial statements,
prepared from information provided by this system, shall be presented in
conformity with U.S. generally accepted accounting principles (GAAP). The
Contractor must also have adequate time keeping and cost allocation systems to
allocate salary cost and indirect cost to appropriate cost centers. Books and
records of the Contractor shall be subject, at any reasonable time, to inspection,
audit or copying by appropriate Federal, State or county personnel, or such
independent auditors or accountants as may be designated by these personnel.
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(2) All billing by the contractor must be in a format approved by the fiscal agent
or county. Contractors must bill the fiscal agent and county at least once a
month. Contractors may bill twice a month, on the 15th and last day of the
month, for services rendered. Bills will be returned unpaid if the bills do not
conform to the approved format or the documentation is inadequate.
(3) All Contractors whose total annual expenditures are $100,000 or more shall
submit an annual audit of their financial statements by an independent certified
public accountant. Contractors with total annual expenditures less than $100,000
may submit an audit as described above or may submit compiled or reviewed
financial statements, prepared in accordance with generally accepted accounting
principles. If the Contractor is a government agency that has an independent audit
done by another agency of that government, its audited financial statements,
prepared in accordance with generally accepted accounting principles for state
and local governments meet this requirement. The audited, compiled or reviewed
financial statements of PRTFs, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs and RCCFs and Attn: Audit Division Director
for CPAs) within 180 days after the contractor's fiscal year end. The audited
financial statements and supplementary information defined in regulation for
various agencies shall be presented as described in Section VI, B (1), above and
must contain sufficient detail to provide evidence of financial accountability
under the terms of this contract and controlling state regulations. Contractors that
are a subsidiary of a parent organization must submit separate financial statements
for the subsidiary that detail each of the Contractor's facilities and/or programs
that provide services for the Colorado Department of Human Services and also
must provide a reconciliation of these financial statements to the consolidated
financial statements of the organization as a whole. When applicable, the
Contractor must comply with the audit requirements found in the Single Audit
Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of
Management and Budget (OMB) Circular A-133, Audits of States, Local
Governments, and Non -Profit Organizations including subsequent revisions, and
appropriate audit and financial reporting requirements as defined in State laws,
rules, and regulations.
(4) If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted. If the contractor is a CPA, then sanctions of the contractor may occur
for failure to submit.
(5) In cases where documentation does not exist to support audit information or
services provided, contractor will be required to repay all funds received for
which documentation does not exist.
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(6) In cases where audit deficiencies are noted, a plan of corrective action shall be
submitted to the State Department's Audit Division for approval within 4 months
of the date of the audit.
(7) Failure to comply with any of these requirements, including items on the
addendum is justification for the County to impose fiscal sanctions, penalties, or
cancel the contract.
6. In the event this contract is terminated, final payment to the Contractor may be
withheld at the discretion of the County until final audit. Incorrect payments to the
Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the
Contractor either by deduction from subsequent payments under this contract or other
contracts between the County and the Contractor or by the County, as a debt due to both
the State of Colorado, the Colorado Department of Human Services and the County. The
waiver of any violation shall not be construed as a waiver of any other or subsequent
violation of this contract or appropriate statutes and regulations.
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
ATTEST: Weld County Cle
By:
Deputy Clerk to the Board
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
WELD COUNTY BOARD
OF SOCIAL SERVICES,
ON BEHALF OF THE
WELD COUNTY
DEPARTMENT OF
HUMAN SERVICES
By:
Chair Signature
CONTRACTOR
«CONTRACTOR_ NAME»
«MAILING ADDRESS»
«CITY STATE ZIP»
By: By:
Director
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11
ra:r4
COLORADO
MEMORANDUM
DEPARTMENT OF HUMAN SERVICES
P.O. BOX A
GREELEY, CO. 80632
Website: www.co.weld.co.us
Administration and Public Assistance (970) 352-1551
Child Support (970) 352-6933
TO: Judy Griego - Director
FROM: Lesley Cobb - Child Welfare Contract Negotiator
DATE: April 30, 2009
SUBJECT: Out -of -home providers to be submitted to the
Board of County Commissioners for Consent.
Attached please find the proposed Weld County Addendums and list of out -of -home providers that I am requesting
to be submitted to the Board of County Commissioners for their consent.
Directory:
Attachment I — RCCF/TRCCF contract and provider list
Rates are based on the State Standard rates from 2008-2009 (also known as base anchor rates). No COLA is being
recommended for the 2009-2010 fiscal year.
Attachment II — County Certified Foster Care contract and provider list
Rates are 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 2009-2010 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 2009-2010 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 CHRP.
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 2009-2010 fiscal year.
Attachment VII — RCCF contract and provider list
Rates are negotiated based on the high level of needs the child requires. These providers 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.
Attachment VIII — TRCCF guarantee bed contracts with Shiloh Home, Inc.
Weld County contracts with this provider to have six (6) guaranteed beds for the County's exclusive use.
Attachment XI — TRCCF guarantee bed contracts with Reflection for Youth, Inc.
Weld County contracts with this provider to have four (4) guaranteed beds for the County's exclusive use.
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, 2009 through June 30, 2010.
The following provisions, made this day of , 2009, 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 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.
3. 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%)
4. 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.
5. 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.
6. 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.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for
staffing current placements with the Utilization Review Team. This review team convenes every
Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County
Department of Human Services to shorten the duration of placement.
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after
placement, dental examinations within eight weeks after placement and forward all appropriate
information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for
youth designated as a Special Education Student will be conducted every 3 years and reviewed 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.
11. Add Paragraph 16 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 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 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
By:
Deputy Clerk to the Board
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
CONTRACTOR
«RCCF_NAME»
«MAILING_ ADDRESS»
«CITY STATE ZIP»
By: By:
Director
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FACILITY FACILITY CITY
ADDRESS STATE ZIP
2950 Denver CO
Tennyson St 80212-3029
Denver CO 80236
Englewood CO
80010
Denver CO 80203
Denver CO 80220
Denver CO 80230
Denver CO 80206
Fort Collins CO
80521
Fort Collins CO
80524
Alamosa CO
81101
Morrison CO
80465
Denver CO 80206
Synergy 3660-80 W
Princeton Cir
4821 S
Bannock St
1133 Lincoln
1735 Pontiac
St
9100 E Lowry
Blvd
1295 York St
614 S
Mathews St
801 S Shields
St
1317 17 St. #8
5924 Highway
285
1508 Fillmore
FACILITY NAME
Tennyson Ctr for Children
@ CO Christian Home
Third Way Center
Third Way Center - Lincoln
Third Way Center - Pontiac
Third Way Center - Lowry
Third Way Center - York
Turning Point- Mathews
Turning Point - Shields
Youthtrack San Luis Valley
YouthTrack Jeffco
Youthtrack (Work & Learn)
FACILITY
ID
45205
49488
1507881
77810
65346
1547437
49487
45179
100441
11725
11724
11726
CITY STATE ZIP RCCF TRCCF
RATE RATE
Denver, CO $180.75 $180.75
80212-3029
$148.49
$179.24
$179.24
$179.24
$175.71
$179.24
$178.02
$178.02
$141.50
$129.23 $129.23
Longmont, CO $137.90 $137.90
80501
$148.49
$179.24
$179.24
N
N
O
N.
S
$175.71
N
N
m
n
S
$178.02
N
O
W
n
N
$141.50
Denver, CO
80236
Denver, CO
80206
Denver, CO
80206
Denver, CO
80206
Denver, CO
80206
PO Box 61385 Denver, CO
80206
Fort Collins, CO
80525
Fort Collins, CO
80525
Longmont, CO
80501
Longmont, CO
80501
RCCF/TRCCF NAME MAILING
ADDRESS
36 Tennyson Center for 2950 Tennyson
Children St
3738 W
Princeton Cir
PO Box 61385
PO Box 61385
PO Box 61385
PO Box 61385
1644 South
College Ave
1644 South
College Ave
1375 Ken Pratt
Blvd
1375 Ken Pratt
Blvd
1375 Ken Pratt
Blvd
The University of Colorado
Health Sciences Center dba
Synergy
Third Way Center
Third Way Center
Third Way Center
Third Way Center
Third Way Center
Turning Point Center for
Youth
Turning Point Center for
Mouth
Youthtrack
Youthtrack
Youthtrack
N-
CO
CO
COV
V
V ���
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, 2009 through June 30, 2010.
The following provisions, made this day of , 2009, 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 Attachment 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 Attachment 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. 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.
5. Add Paragraph 7 to Section 1. 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 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.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. Contractor
shall be notified by Department staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 8 weeks after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed 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.
11. Add Paragraph 16 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 Social 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 Social 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 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.
17. Add Section VII - ATTACHMENTS:
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME
STATE ID#
SEX [TRAILS CASE ID
M F
DOB
WORKER COMPLETING ASSESSMENT �IH#
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?
O Basic Maint.) Less than one round trip a week
❑2) 3-4 round trips a week.
O3%) 7 round trips or more
❑ 1) One round trip a week ❑ 1'/n) 2 round trips a week
❑2%:) 5 round trips a week O3) 6 round trips a week
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.) No participation required
O2) Three times a month
❑3') Three times a week or more
01) Once a month ❑1'/) Two times month
O2%) Once a week ❑3) Two times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.) No educational requirements
O2) 1 hour a day
O 3%) More that 3 hours per day
01) Less than a''/3 hour per day ❑l'/)'/z hour a day
O2 /) 1'h-2 hours per day O3) 2'/z-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
O2) 8 to 10 hours per week
0 3) Constant basis during awake hours
01) Less than 5 hours per week ❑1%,) 5 to 7 hours per week
O2%) 11 to 14 hours per week
O3%) Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding.
bathing, grooming, physical, and/or occupational therapy?
❑ Basic Maint.) 0-2 hours per week DI) 3 to 4 hours per week ❑1%) 5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2'/) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3/) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01) Face-to-face contact one time per month with child and minimal crisis intervention.
❑ 1/) Face-to-face contact one time per month with child and occasional crisis intervention.
O2) Face-to-face contact two times per month with child and occasional crisis intervention.
❑2'/:) Face-to-face contact three times per month with child and occasional crisis intervention.
O3) Face-to-face contact weekly with child and occasional crisis intervention.
❑3'%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑ 0) Not needed or provided by another source (Le. Medicaid) ❑ 1) Less than 4 hours per month
❑ 2) 4-8 hours per month ❑3) 9-12 hours per month
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions
(Check one box for each category)
None
Mild
Mild/
Moderate
/ Hi h
2 1/2
High
High/
Severe
Comments:
0
Assessment Areas Moderate Moderate
1
1 1/2
2
3
3 1/2
Aggression/Cruelty to
Animals
❑
❑
❑
❑
❑
❑
❑
Verbal or Physical
Threatening
❑
❑
❑
❑
❑
❑
•
Destructive of
Property/Fire Setting
❑
❑
❑
❑
❑
❑
•
Stealing
❑
❑
❑
❑
❑
❑
❑
Self -injurious Behavior
❑
❑
❑
❑
❑
❑
❑
Substance Abuse
❑
❑
❑
❑
❑
❑
■
Presence of Psychiatric
Symptoms/Conditions
❑
❑
❑
❑
❑
•
Enuresis/Encopresis
❑
❑
❑
❑
❑
❑
❑
Runaway
❑
❑
❑
❑
❑
❑
❑
Sexual Offenses
❑
❑
❑
❑
❑
❑
■
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions
(Check one box for each category)
Assessment Areas
None
Mild
1
Mild/
Moderate
Moderate
Moderate
/ Hi h
21/2
Hid,
High/
Severe
S
Comments:
0
11/2
2
3
31/2
Disruptive Behavior
❑
❑
❑
❑
❑
❑
❑
Delinquent Behavior
❑
❑
❑
❑
❑
❑
•
Depressive -like Behavior
❑
❑
❑
❑
❑
❑
❑
Medical Needs
(If condition is rated "severe",
please complete the Medically
fragile NBC)
❑
❑
❑
❑
❑
❑
❑
Emancipation
❑
❑
❑
❑
❑
❑
❑
Eating Problems
❑
❑
❑
❑
❑
❑
❑
Boundary Issues
❑
❑
❑
❑
❑
❑
❑
Requires Night Care
❑
❑
❑
❑
❑
❑
❑
Education
❑
❑
❑
❑
❑•
•
Involvement with Child's
Family
❑
❑
❑
❑
❑
❑
❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ I ❑ 1'// ❑ 2 ❑ 2'// ❑
3 ■ 3'/z
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
LEVEL
OF
SERVICE
RECOMMENDED
PROVIDER RATE
PI -P5
RECOMMENDED AGENCY RATE
Al
THERAPY RATE
T1
MEDICAL
NEEDS
ADDENDUM
Level
Rate
Case Management
(Admin. Maint.)
Therapy
(Admin. Services)
Level
County
Basic
Maint.
Age 0-10...$16.32
($496)
Age 11-14...$18.05
($549)
Age 15-21...$19.27
($586)
+ $.66 Respite Care
($20)
Basic Maint $4.93 day/$15omo
No crisis intervention, Minimal CPA
involvement, one face-to-face visit
with child per month.
Level 0 $0
Therapy not needed or provided
by
another source, i.e. mental health.
Level 0...$0
(None)
1
$19.73
+$.66 Respite Care
($20.39 day/$620 mo)
Level 1 $8.22 day/$250 mo
Minimal crisis intervention as needed,
one face-to-face visit per month with
child,
2-3 contacts per month
Level 1 $4.93/$150 mo
Regularly scheduled therapy,
up to 4 hours/month.
Level 1 ...$2.99
1 1/2
$23.01
+$.66 Respite Care
($23.67 day/$720 mo)
Level 1 1/2 $9.86 day/$300 mo
2
$26.30
+$.66 Respite Care
($26.96 day/$820 mo)
Level 2 $11.51 day/$350 mo
Occasional crisis intervention as needed,
two face-to-face visits with child,
2-3 contacts per month
Level 2 $9.86/$300 mo
Weekly scheduled therapy,
5-8 hours a month with 4 hours of
group therapy.
Level 2..$4.47
2 112
$29.59
+$.66 Respite Care
($30.25 day/$920 mo)
Level 2 1/2 $13.15 day/$400 mo
3
$32.88
+$.66 Respite Care
($33.54day/$1020 mo)
Level 3 $14.79 day/$450 mo
Ongoing crisis intervention as needed,
weekly face-to-face visits with child,
and intensive coordination of
multiple services.
Level 3 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 3..$6.02
3 1/2
$36.16
4-$.66 Respite Care
($36.82 day/$1,120 mo)
Level 3 1/2 $16.44 day/$500 mo
4
RTC Drop
Down
$39.45
+$.66 Respite Care
($40.11 day/$1220 mo)
Level 4 $18.08 day/$550 mo
Ongoing crisis intervention as needed,
which includes high level of case
management and CPA involvement with
child and provider and 2-3 face-to-face
contacts per week minimum.
Level 4 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 4....Neg.
Assess/
Emergency
Level
Rate
(30 Day
Max)
$30.25 day/$920 mo
(Includes Respite)
$13.15 day/$400 mo
Admin. Overhead Rate:
As of 7/01/08
$6.91 day/$210.00 month
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
By:
Deputy Clerk to the Board
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Director
WELD COUNTY BOARD OF SOICAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
CONTRACTOR
«CPA_NAME»
«MAILING ADDRESS»
«CITY STATE ZIP»
By:
CPA PROVIDER NAME
FACIDLITY
MAILING ADDRESS
CITY STATE ZIP
1
Adoption Alliance
71259
2121 S. Oneda St, Suite 420
Denver, CO 80224
2
Adoption Options
45078
13900 E Harvard Ave, Suite 200 Aurora, CO 80014
3'Ariel
Child Placement Agency
90205
4251 Kipling St, Unit 500 Wheat Ridge, CO 80033-2899
4
Bethany Christian Services
45514
4820 Rusina Rd, Suite C Colorado Springs, CO 80907-
8127
5
Bridges Inc.
1980
1225 N Main Street, Suite 102 Pueblo, CO 81003
6
Colorado Family Services, Inc.
26885
1200 S. Wadsworth #300 Lakewood, CO 80232
7
Commonworks D.B.A. Synthesis
104085
3000 Youngfi;55 Street, Suite
Lakewood CO 80215
8
Denver Area Youth Services
45069
1240 W Bayaud
Denver, CO 80223
9
Frontier Family Services
38041
1290 Boston Ave
Longmont, CO 80501-5810
10
Gateway Youth and Family
95568
740 Gunnison Ave
Grand Junction, CO 81501
11
Hope & Home
29867
1925 Dominion Way, Ste 200
Colorado Springs, CO 80918
12
Hope Family Services
42942
1610 29th Ave Place #100
Greeley, CO 80634
13
Imagine
21369
1400 Dixon Ave
Lafayette, CO 80026
14
Kids Crossing
79752
1440 E Fountain Blvd
Colorado Springs, CO 80910-
3502
15
Lost and Found Inc.
57351
6700 44th Ave
Wheatridge, CO 80033
16
Loving Homes Inc.
72767
127 S Union Ave
Pueblo CO 81003
17
Lutheran Family Services of
Colorado
45080
2032 Lowe Street, Suite 200
Fort Collins, CO 80525
18
Maple Star Colorado
90967
2250 S Oneida Street, Suite 100
Denver, CO 80224-2557
19
REM Colorado, Inc.
37832
4815 List Dr, Suite 111
Colorado, Springs CO 80919-
3340
20
Savio House
37330
325 King Street
Denver, CO 80219
21
Smith Agency Inc.
44882
7169 S Liverpool St
Centennial, CO 80016
22
WhimSpire CPA
19562
309 S Cascade Ave
Montrose, CO 81401
23
Youth Ventures of Colorado
1554849
4785 Granby Cir
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, 2009 through June 30, 2010.
The following provisions, made this day of , 2009, 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. 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.
4. 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.
5. 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, mentor/advocate, and supervised visitation.
6. 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.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for
staffing current placements with the Utilization Review Team. Contractor shall be notified by
Department staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County
Department of Human Services to shorten the duration of placement.
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days and dental
examinations within 8 weeks of the child being placed with Contractor. All documentation of these
examinations shall be forward to the appropriate county staff.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for
youth designated as a Special Education Student will be conducted every 3 years and reviewed 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.
11. Add Paragraph 16 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
By:
Deputy Clerk to the Board
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Director
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
CONTRACTOR
<<CENTER_NAME»
MAILING_ADDRESS»
«CITY STATE ZIP»
By:
GROUP
CENTER
NAME
MAILING
ADDRESS
CITY STATE
ZIP
PROVIDER
RATE
FACILITY
ID
FACILITY
NAME
FACILITY
ADDRESS
FACILITY
CITY STATE
ZIP
1
A Kidz Hope
Homes Inc.
1401 W
Colorado Ave
Colorado
Springs, CO
80904
$89.13
1531612
A Kidz Hope
Annex
116 S 14th
Street
Colorado
Spring, CO
80904
2
A Kidz Hope
Homes Inc.
1401 W
Colorado Ave
Colorado
Springs, CO
80904
$95.00
1531611
A Kidz Hope
1401 W
Colorado Ave
Colorado
Springs, CO
80904
3
Evergreen
Group Center
1436 Hilltop Dr.
Longmont, CO
$95.00
61317
Evergreen
1436 Hilltop
Longmont,
CO 80501
4
Griffith Center
for Children
14142 Denver
West Pkwy,
Suite 225
Lakewood, CO
$115.00
1543863
8O4O1 Home Ave
Prospect Youth
28 Farragut
Colorado
Springs, CO
80909
5
14142 Denver
Griffith Center
for Children West Pkwy,
Suite 225
Lakewood, CO
80401
$115.00
1531601
Meridian Youth
Ranch
11875 Smith
LN
Peyton, CO
80831
6
Heritage PO Box 195
Louisville, CO
$100.00
1520452
Heritage House
333 East
Louisville, CO
80027
7
Kids Crossing
1440E
Fountain Blvd
Colorado
Springs, CO
80033
$95.34
1552984
Second Chance
12799
Exposition
Dr.
Aurora, CO
80012
8
Kids Crossing
1440E
Fountain Blvd
Colorado
Springs, CO
80033
95.34
1551132
Helping Hands
Group Home
21622 E
Alamo Place
Centennial,
CO 80015
9
Loving
Homes, Inc.
127 S Union
Ave
Pueblo, CO
81003-3459
$71.11
8822
Loving Homes
2215
Montezuma
Pueblo, CO
81003
10
Maple Star
Colorado
2785 Speer
Blvd, Suite 340
Denver, CO
80211
$86.00
13416
Christi Beach
Group Home
6233 Xavier
Street
Arvada, CO
80003
11
REM 4815 List Dr,
Colorado, Inc. Suite 111
Colorado,
Springs CO
80919-3340
$250.00
1535698
REM Colorado,
Inc. Wisteria
Center
5845 Wisteria
Dr
Colorado
Springs, CO
80919
12
Savio House 325 King Street
Denver, CO
80219
$106.96
1517239
The Lampkin
Home
2836 Vine
Denver, CO
80205
13
Savio House
325 King Street
Denver, CO
80219
$106.96
1548844
J CS Jorney For
Girls
705 S Harlan
Street
Lakewood,
CO 80226-
4719
14
Savio House
325 King Street
Denver, CO
80219
$106.96
1548445
Carr Group
Center for Girls
3297
Jasmine
Street
Denver, CO
80207
15
Savio House
325 King Street
Denver, CO
80219
$81 24
5628
Wilson Group
Home
15005
Maxwell PI
Denver, CO
80239
16
Smith Agency
DBA Serenity
IX
7169 S
Liverpool St
Centennial, CO
80016
$144.23
1540493
Serenity IX
4195 S
Pagosa Ct
Aurora, CO
80013
17
Youth
Ventures of
Colorado
4785 Granby
Cir
Colorado
Springs, CO
80919
$91.60
2611
F.I.C.O.S.A.
20765 Oasis
Ave
Peyton, CO
80831
18
Youth
Ventures of
Colorado
4785 Granby
Cir.
Colorado
Springs, CO
80919
$91.60
1530211
Youth Alliance
2610
Montebello
Dr. W
Colorado
Springs, CO
80918
19
Youth
Ventures of
Colorado
4785 Granby
Cir.
Colorado
Springs, CO
80919
$91.60
1545224
Ricky's House
4415 E San
Miguel
Colorado
Springs, CO
80915
GROUP
CENTER
NAME
MAILING
ADDRESS
CITY STATE
ZIP
PROVIDER
RATE
FACILITY
ID
FACILITY
NAME
FACILITY
ADDRESS
FACILITY
CITY STATE
ZIP
20
Youth
Ventures of
Colorado
4785 Granby
Cir.
Colorado
Springs, CO
80919
$91.60
15801
Future Bound
3101 Palmer
Park Blvd
Colorado
Springs, CO
80909
21
Youth
Ventures of
Colorado
4785 Granby
Cir.
Colorado
Springs, CO
80919
$91.60
1534441
LaMar Place
3590 LaMar
PI
Colorado
Springs, CO
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, 2009 through June 30, 2010.
The following provisions, made this day of , 2009, 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 $<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 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.
3. 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%)
4. 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.
5. 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.
6. 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.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for
staffing current placements with the Utilization Review Team. Provider shall be notified by Department
staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County
Department of Human Services to shorten the duration of placement.
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after
placement, dental examinations within 8 weeks after placement and forward all appropriate information
to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for
youth designated as a Special Education Student will be conducted every 3 years and reviewed 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.
11. Add Paragraph 16 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 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 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
By:
Deputy Clerk to the Board
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Director
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
CONTRACTOR
«RCCF_NAME»
«MAILING_ ADDRESS»
«CITY STATE ZIP»
By:
RCCF
PROVIDER
NAME
MAILING
ADDRESS
CITY STATE
ZIP
PROVIDER
RATE
FACILITY
ID
FACILITY
NAME
FACILITY
ADDRESS
FACILITY
CITY STATE
ZIP
1
Roundup
Fellowship
2250 S
Oneida,Suite80224
Denver, CO,
$147.77
45105
Roundup
Fellowship I
1345 St Paul
St
Denver, CO,
80206
2
Roundup
Fellowship
2250 S
Oneida, Suite
201
Denver, CO,
80224
$147.77
45211
Roundup
4441 Fortune
Colorado
Springs, CO,
3
Roundup
Fellowship
2250 S
Oneida, Suite
201
Denver, CO,
80224
$147.77
45212
Roundup
Fellowship V
1234 N
Meade St
Colorado
Springs, CO
80909
4
Smith Agency
7169 S.
Liverpool St.
Centennial,
CO 80016
$147.77
6566
Serenity II
Childrens
Home
14759 E.
Pacific PI
Aurora, CO
80014
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, 2009 through June 30, 2010.
The following provisions, made this day of , 2009, 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. Add Paragraph 5 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, mentor/advocate, and supervised visitation.
4. 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.
5. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for
staffing current placements with the Utilization Review Team. Provider shall be notified by Department
staff of the date and time of the utilization review.
6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County
Department of Human Services to shorten the duration of placement.
7. Add Paragraph 14 to Section IV. To schedule physical and dental examinations within 24 hours after a
child is placed in provider's care. Medical examinations need to be completed within 14 days and dental
examinations need to be 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.
8. Add Paragraph 15 to Section IV. Meet with the Department of Human Services supervisor for a
minimum of two hours weekly (7.709.21), the specialized group home parent will also be available to
meet with Weld County's assessment specialist for the purpose of measuring the youth's level of
functioning.
9. Add Paragraph 16 to Section IV. Expect and welcome home visits from caseworkers, mental health
professionals, GALs, CASA volunteers, mentors and family members when appropriate.
10. Add Paragraph 17 to Section IV. Attend trainings focused on issues commonly faced by high -risk
youth. The trainings will be sponsored by the Weld County Department of Human Services. The group
home parent is encouraged to invite their respite provider(s) to the monthly trainings. Hours spent in
training by the specialized group home parent may be applied to annual training requirements mandated
in section 7.714.170 in the State Quality Standards.
11. Add Paragraph 19 to Section IV. As an important member to the youth's treatment team, the specialized
group home parent will accompany other key professionals to school conferences, IEP meetings, or
school -related staffings.
12. Add Paragraph 20 to Section IV. Furnish transportation as advised in the State Quality Standards
(7.714.200). Transportation to and from appointments may include, but are not limited to, visitation
with family members, medical/dental or mental health appointments, extracurricular school activities,
court hearings or other specialized programming.
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 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.
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 Human 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
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 Paragraph 11 to Section VI. Both Contractor and the County will collaborate to modify this
contract as necessary.
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
By:
Deputy Clerk to the Board
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Director
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
CONTRACTOR
«CENTER NAME»
«MAILING_ADDRESS»
«CITY STATE ZIP»
By:
SPECIALIZED GROUP HOME
PROVIDER
FACILITY
RATE
FACILITY
ID
FACILITY NAME
FACILITY
ADDRESS
FACILITY CITY
STATE ZIP
1
C & E Group Home
$50.04
1519595
C & E Group Home
3920 W 13th
Street
Greeley CO 80634
2
C & M Group Home
$50.04
9875
C & M Group Home
1920 81st Ave
Greeley CO 80634
3
Earl and Cindy Almond
$50.04
61603
Almond Group
Home
1937 Chestnut
Ave
Greeley CO 80631
4
Marie Alirez Group Home
$50.04
70335 Marie Alirez Group
Home
1405 26th Street
Greeley CO 80631
5
Michael Alirez Group Home $50.04
54150 Michael Alirez
Group Home
1709 37th Ave
Greeley CO 80634
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, 2009 through June 30, 2010.
The following provisions, made this day of , 2009, 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 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.
3. 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%)
4. 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.
5. 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.
6. 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.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for
staffing current placements with the Utilization Review Team. Provider shall be notified by Department
staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County
Department of Human Services to shorten the duration of placement.
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after
placement, dental examinations within 8 weeks after placement and forward all appropriate information
to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for
youth designated as a Special Education Student will be conducted every 3 years and reviewed 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.
11. Add Paragraph 16 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 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 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
By:
Deputy Clerk to the Board
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Director
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
CONTRACTOR
«RCCF NAME»
«MAILING_ADDRESS»
«CITY STATE ZIP»
By:
RCCF
PROVIDER
MAILING
ADDRESS
CITY STATE
ZIP
RCCF
RATE
FACILITY
ID
FACILITY
NAME
FACILITY
ADDRESS
FACILITY
CITY STATE
ZIP
1
Attention Homes
3080 Broadway,
Suite C
Boulder, CO
80304
$130.00
7496
Attention
Homes
3080 Broadway,
Suite C
Boulder CO
80304
2
Dale House
Project
7 W Dale St
Colorado
Springs, CO
80903
$110.29
1502911
Dale House
Project
24 E Dale St
Colorado
Springs CO
80903
3
Indiana
Developmental
Training Center
11075 North
Pennsylvania
Street
Indianapolis,
IN 46280
$436.07
1524668
IDTC
11075 North
Pennsylvania
Street
Indianapolis,
IN 46280
4
Mount Saint
Vincent
4159 Lowel
Blvd
Denver, CO
80211
$138.88
1541575
Aspen House
At Mount
Saint Vincent
4157 Lowell
Blvd
Denver CO
80211
5
Youth Villages
PO Box 341154
Memphis, TN
38184-1154
$390.00
1511780
Youth
Villages
7410 Memphis
Arlington Rd
Bartlett TN
38135
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