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Home My WebLink About20091874.tiffMEMORANDUM fi WIlD COLORADO RE: 0 • FROM: Judy A. Griego, Director, Human Services DATE: July 30, 2009 TO: William F. Garcia, Chair, Weld County Board of Con r}is 'oners ,j individual Provider Contract for Purpose of Oster Care Services and Foster Care Facility Agreement and Weld County Addendum to Individual Provider Contract for Purpose of Foster Carc Services and Foster Care Facility between the Weld County Department of Human Services and Various Contractors to be Placed on the Consent Agenda Enclosed for Board approval arc Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreement and Weld County Addendums to Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility between the Weld County Department of Human Services and Contractors listed below. Please place on the Consent Agenda. Below arc the major provisions of the attached Agreements: No. Facility Name/Term Type of Facility/Location Daily Rate 1 Armfield, Pamela July I. 2009 — June 30, 2010 Foster Home Pierce. Colorado $16.32-$40.11 2 Baker, Elissa July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 3 Beasley, Travis and Sarah July 1, 2009 — June 30, 2010 Foster Home Longmont, Colorado $16.32-$40.11 4 Burden, Craig and Lea July 1.2009 — June 30, 2010 Foster Home Greeley. Colorado $16.32-$40.11 - Carter, Jeremy and Susan July 1.2009 — June 30, 2010 Foster Home Greeley. Colorado $16.32-$40.11 6 Corliss, Wade and Loni July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 7 Cowper, Michael and Alecia July I, 2009 — June 30, 2010 Foster Home Platteville, Colorado $16.32-$40.11 8 Dietz, Bill and Wilma July 1, 2009 — June 30, 2010 Foster Home Ault, Colorado $16.32-$40.11 9 Downey, John and Donna July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 10 Fisher, Matthew and Claire July 1, 2009 — June 30, 2010 Foster Home Greeley. Colorado $16.32-$40.11 11 Gerardy, Jerry and Priscilla Jule 1, 2009 - June 30, 2010 Foster Home Evans. Colorado $16.32-$40.11 12 Goodman, Bob and Katie July 1, 2009 — June 30, 2010 Foster Home Windsor. Colorado $16.32-$40.11 mil' 8151 2009-1874 13 Helmer, Sara July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 14 Lewis, David and Connie July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 15 Maronck, Dennis and Patricia July 1, 2009 — June 30, 2010 Foster Home Firestone, Colorado $16.32-$40.11 16 Mauk, James and Harriett July 1, 2009 — June 30, 2010 Foster Home Johnstown, Colorado $16.32-$40.11 17 McCrecry, James and Tammy July 1, 2009 — June 30, 2010 Foster Homc Eaton, Colorado $16.32-$40.11 18 McGee, Donna July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 19 Mellmen, Jeffrey and Letha July 1, 2009 - June 30, 2010 Foster Home Eaton, Colorado $16.32-$40.11 20 Mena, David and Marie July 1, 2009 - June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 21 Moore, Earl and Patricia July 1, 2009 - June 30, 2010 Foster Home Lochbuie, Colorado $16.32-$40.11 22 Munnclly, John and Heidi July 1, 2009 - June 30, 2010 Foster Home Windsor, Colorado $16.32-$40.11 ? Foster Home $16 32 $40 11- -Jnly-T; 2065----June-30•, 20-11L Greeley, Colorado 24 Pluma, Mike and Annette July 1, 2009 - June 30, 2010 Foster Home Kersey, Colorado $16.32-$40.11 25 Preston, Daniel and Lisa July 1, 2009 - June 30, 2010 Foster Home Windsor, Colorado $16.32-$40.11 26 Purcella, Denise July 1, 2009 - June 30, 2010 Foster Home Firestone, Colorado $16.32-$40.11 27 Ramos, Julian July 1, 2009 - June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 28 Ransome, Christopher and Mary July I, 2009 - June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 29 Rasmussen, Dennis and Diane July 1, 2009 - June 30, 2010 Foster Home Johnstown, Colorado $16.32-$40.11 30 Rothe, Terry and Marilyn July 1, 2009 - June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 31 Sands, Corey and Amy July 1, 2009 - June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 _ Schmidt, Donald and -Constance Festei Home- Groe1cy, Celeeade $16.32 $40.11 July 1, 2009 - J 30, 2018 33 Sevestre, Lewis and Maureen July 1, 2009 -June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 34 Skeldum, William July 1, 2009 — June 30, 2010 Foster Home Johnstown, Colorado $16.32-$40.11 35 Slaughenhaupt, Gary and Grace July 1, 2009 — June 30, 2010 Foster Home Eaton, Colorado $16.32-$40.11 36 Steitz, Daniel and Natalie July 1, 2009 —June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 37 Van Den Ellen, Dawn July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 39 Wade, Michael and Jodync July 1, 2009 — June 30, 2010 Foster Home Windsor. Colorado $16.32-$40.11 39 White, Richard and Melissa July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $ 16.32-$40.11 40 Willert, Melody D. and Lee, Kimberly July 1, 2009 —June 30, 2010 Foster Home LaSalle, Colorado $16.32-$40.11 41 Brilla, Debbie July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 42 Cordova, Freddie and Linda July 1, 2009 — June 30, 2010 Foster Home Evans, Colorado $16.32-$40.11 43 Fox, Ryan and Emily July 1, 2009 --- June 30, 2010 Foster Home Brighton, Colorado $16.32-$40.11 44 Hendrix, Samuel and Shanaine July 1, 2009 — June 30, 2010 Foster Home Firestone, Colorado $16.32-$40.11 45 Hernandez, Roberto and Margarita July 1, 2009 — June 30, 2010 Foster Home Fort Lupton, Colorado $1632440.11 46 Holmgren, David and Dawn July 1, 2009 — June 30, 2010 Foster Home Windsor, Colorado $16.32-$40.11 47 Hunt, Olen J. and Nina July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 48 Jackson, Scott and Andrea July 1, 2009 — June 30, 2010 Foster Home Johnstown, Colorado $16.32-$40.11 49 Kilgore, Julius and Pamela July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 50 Kniss, Kevin and Kelly July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40,11 51 Loschen, Todd and Alicia July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 52 Middleton, Briand and Deboarah July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 53 Murrell, Nicholas and Terri July 1, 2009 — June 30, 2010 Foster Home Windsor, Colorado $16.32-$40.11 54 Parker, Brian and Beryldell July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 55 Redding, Christopher and Sonja July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 56 Reyna, Ali and Jessica July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 57 Ripka, Gary and Jennifer July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 58 Ritter. Thomas and Deborah July 1, 2009 — June 30, 2010 Foster Home Firestone, Colorado $16.32-$40.11 59 Rogers, Jeffrey and Tami July 1, 2009 — June 30, 2010 Foster Home Firestone, Colorado $16.32-$40.11 60 Shindle, Danny and Andrea July 1, 2009 — June 30, 2010 Foster Home Greeley, Colorado $16.32-$40.11 61 Walker, Kurt and Jennifer July 1, 2009 — June 30, 2010 Foster Home Windsor, Colorado $16.32-$40.11 If you have any questions, give me a call at extension 6510. istzp; COLORADO TO: FROM: DATE: SUBJECT: 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 MEMORANDUM Judy Griego — Director Lesley Cobb--pChild Welfare Rate Negotiator 1J July 6, 2009 ' The Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreement and the Weld County Addendum to those contracts. Attached please find the Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements and the Weld County Addendums to those contracts for the following County foster care providers: Weld County Foster Care Providers 2009-2010 1 2 3 Beasley, Travis and Sarah 4 Burden, Craig and Lea 5 Carter, Jeremy and Susan 6 Corliss, Wade and Loni 7 Cowper, Michael and Alecia 8 Dietz, Bill and Wilma 9 Downey, John and Donna Armfield, Pamela Baker, Elissa 1549727 1552821 1552607 1552261 1556173 1547483 1526756 8635 1551054 PO Box 254 2613 15th Ave Ct 840 Grandview Meadows Dr. #A101 2203 A Street 3332 W 35th St 26649 CR 60 1/2 509 N Sholdt Dr 21257 Hwy14 3826 W. 8th Street Pierce, CO 80650 Greeley, CO 80634 Longmont, CO 80503 Greeley, CO 80631 Greeley, CO 80634 Greeley, CO 80631 Platteville, CO 80651 Ault, CO 80610 Greeley CO 80634 18 19 20 21 22 23 24 25 26 27 28 29 30 31 10 Fisher, Matthew and Claire 11 Gerardy, Jerry and Priscilla 12 Goodman, Bob and Katie 13 Heimer, Sara 14 Lewis, David and Connie 15 Maronek, Dennis and Patricia 16 Mauk, James and Harriett 17 McCreery, James and Tammy McGee, Donna Mellmen, Jeffrey and Letha Mena, David and Marie Moore, Earl and Patricia Munnelly, John and Heidi Paulsen, Larry and Helen Pluma, Mike and Annette Preston, Daniel and Lisa Purcella, Denise Ramos, Julian Ransome, Christopher and Mary Rasmussen, Dennis and Diane Rothe, Terry and Marilyn Sands, Corey and Amy r'nnefoneo 33 Sevestre, Lewis and Maureen 34 Skeldum, William 35 Slaughenhaupt, Gary and Grace 36 Steitz, Daniel and Natalie 37 Van Den Elzen, Dawn 38 Wade, Michael and Jodyne 39 White, Richard and Melissa 40 Willert, Melody D and Lee, Kimberly 1532312 1530549 1552796 1547292 1523277 5022 W 2nd St Rd 3408 Cody Ave 8134 Louden Circle 3000 W 19th St 2904 42nd Ave 4860 Eagle Crest 1520627 Blvd 1537621 3620 Dilley Circle 40215 120 Maple Ave 1539853 1649 31st Ave 1547484 352 Laurel Ave 1510691 2905 41st Ave 1517579 135 Poplar St 1523563 291 Columbus St 42268 1939 Homestead Rd 35126 PO Box 34 1548050 611 Cornerstone Dr 10656 Bald Eagle 1551571 Circle 37631 2604 49th Ave 1552605 436 26th Ave Ct 104555 15169 1555552 1511343 1551169 16666 345 Gypsum Lane 4115 W 20th St Rd 2026 27th Ave 4306 W. 30th St Rd 1717 69th Ave 5113 Saguaro Ct 1544611 30633 CR 78 1546930 1701 Elder Ave 44282 7219 W 20th St Ln 1554152 1016 Cottonwood Dr 1545830 3109 W 13th St 1540372 219 N 4th St Greeley, CO 80634 Evans, CO 80620 Windsor, CO 80528 Greeley, CO 80634 Greeley, CO 80634 Firestone, CO 80504 Johnstown, CO 80534 Eaton, CO 80615 Greeley, CO 80634 Eaton, CO 80615 Greeley, CO 80634 Lochbuie, CO 80603 Windsor, CO 80550 Greeley, CO 80634 Kersey, CO 80644 Windsor, CO 80550 Firestone, CO 80504 Greeley, CO 80634 Greeley, CO 80634 Johnstown, CO 80534 Greeley, CO 80634 Greeley, CO 80634 Greeley, CO 80634 Greeley, CO 80634 Johnstown, CO 80534 Eaton, CO 80615 Greeley, CO 80631 Greeley, CO 80634 Windsor, CO 80550 Greeley, CO 80634 LaSalle, CO 80645 These contracts have been presented for consent approval to the Board of County Commissioners however; I am requesting your signature along with the Boards to complete these contracts for the FY 2009-2010. If you have any questions please call me at Ext. 6441. istrn 11111De COLORADO TO: FROM: DATE: SUBJECT: 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 MEMORANDUM Judy Griego — Director Lesley Cobb - Child Welfare Rate Negotiator July 15, 2009 1) The Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreement and the Weld County Addendum to those contracts. Attached please find the Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements and the Weld County Addendums to those contracts for the following County foster care providers: Weld County Foster Care Providers 2009-2010 1 Brilla, Debbie 2 Cordova, Freddie and Linda 3 Fox, Ryan and Emily 4 Hendrix, Samuel and Shanaine 5 Hernandez, Roberto and Margarita 6 Holmgren, David and Dawn 7 Hunt, Olen J and Nina 8 Jackson, Scott and Andrea 30451 1556594 1521088 1553157 1520297 1522699 2018 20th St Rd 4017 Harbor Ln 377 Dogwood Ave 6606 Tenderfoot Ave 912 Elm Ct 101 Poudre Bay 1503154 224 48th Ave 1536689 425 Hickory Ln Greeley, CO 80631 Evans, CO 80620 Brighton, CO 80601 Firestone, CO 80504 Fort Lupton, CO 80621 Windsor, CO 80550 Greeley, CO 80634 Johnstown, CO 80534 9 10 11 12 13 14 15 16 17 18 19 20 21 Kilgore, Julius and Pamela Kniss, Kevin and Kelly Loschen, Todd and Alicia Middleton, Brian and Deborah Murrell, Nicholas and Terri Parker, Brian and Beryldell Redding, Christopher and Sonja Reyna, Ali and Jessica Ripka, Gary and Jennifer Ritter, Thomas and Deborah Rogers, Jeffrey and Tami Shindle, Danny and Andrea Walker, Kurt and Jennifer 1538189 1740 7th Ave 1524303 1545 71st Ave 1528352 1537851 1547183 1538709 1524128 1502220 1538429 1554009 1550689 1550177 1546248 1747 68th Ave 2418 W. 24th St Rd 812 Scotch Pine Dr 230 N 53rd Ave PI 2305 42nd Ave 3304 Syrah St 2113 74th Ave 10151 Devonshire St 5221 Bowersox Parkway 1606 Fairacres Rd. 519 Trout Creek Ct Greeley, CO 80631 Greeley, CO 80634 Greeley, CO 80634 Greeley, CO 80634 Windsor, CO 80550 Greeley, CO 80634 Greeley, CO 80634 Greeley, CO 80634 Greeley, CO 80634 Firestone, CO 80504 Firestone, CO 80504 Greeley, CO 80631 Windsor, CO 80550-3194 These contracts have been presented for consent approval to the Board of County Commissioners however; I am requesting your signature along with the Boards to complete these contracts for the FY 2009-2010. If you have any questions please call me at Ext. 6441. INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, w.N IS, a-81by and between the Board of Weld County Commissioners, sitting as the oard of Soda( Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Armfield, Pamela, Provider ID#1549727, PO Box 254, Pierce, CO 80650, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. 12. 13. 14. To invite the provider to Administrative Reviews for Children in placement. To incorporate provider information in planning for the child. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld Count B Cler. t Deputy C •rk to fhe :oard 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 PROVIDER Armfield, Pamela PO Box 254 Pierce, CO 80650 AUG 0 5 2009 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Armfield, Pamela and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I$ day of , N e , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1549727. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑ Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month ❑3%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month 02%) Once a week 03) 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 ❑1) Less than a %z hour per day 01%) 1/2 hour a day 02) I hour a day 02 %) 1'/-2 hours per day 03) 2'/-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? 0 Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑ Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-i WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a to this child. Verbal or Physical Threatening Destructive of Property/Fire Setting El Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7 BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 ❑ 0 ❑ 0 0 Disruptive Behavior 0 Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems 0 Boundary Issues Requires Night Care Education Involvement with Child's Family 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2%2 ❑ 3 ❑ 3'/2 6 Weld County Addendum to the C W S-7 WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7 S-7 IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to B Deputy C erk to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN \\ SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Armfield, Pamela PO Box 254 Pierce, CO 80�� 8 Weld County Addendum to the CWS-7A_ 0c7. /c'7i INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date,()RJI� by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Baker, Elissa, Provider ID#1552821, 2613 15th Ave Ct, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Serv4es. c_ 6. To keep confidential the information shared about the child and his/her family. N 7. Not to accept money from parents or guardians. 1J 8. Not to make any independent agreement with parents or guardians. if 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 2761°%-/P7 ' 1 t. To give the County Department two weeks notice, except in an emergency, to remove a child for ' placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk t B Deputy • erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES r By: Chair Signature pUG 0 5 2009 PROVIDER Baker, Elissa 2613 15th Ave Ct Greeley, CO 80634 By: (J OA- CS 3 ?DO%_ /J'j/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Baker, Elissa and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this ON day of A , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1552821. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 /L Weld County Addendum to the CWS-7A P7 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week O2%) 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? asic Maint.) No participation required ❑2) Three times a month ❑3'%) Three times a week or more Comments: ❑1) Once a month ❑1%) Two times month ❑2%:) Once a week O3) 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? E Basic Maint.) No educational requirements ❑l) Less than a %: hour per day ❑1 %) ''/ hour a day O2) 1 hour a day O2 %) 1'h-2 hours per day O3) 2Yz-3 hours per day O3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week to 10 hours per week O2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: /:) 5 to 7 hours per week ❑2) 8 P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑ 1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) Mica -Sic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 0) Not needed or provided by another source (i.e. Medicaid) ❑l) Less than 4 hours per month O2) 4-8 hours per month O3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse NI 0 Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway 0 Sexual Offenses I 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a r r 1 to this child. Inappropriate Sexual Behavior 0 ❑ 0 0 0 0 Disruptive Behavior i o O O O o O Delinquent Behavior ./ O O O O O O Depressive -like Behavior V 0 0 0 O O O Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) 0 / 0 O 0 O O Emancipation O O O 0 0 0 Eating Problems E 0 O 0 0 0 o Boundary Issues I O o o o o O Requires Night Care 0 O 0 0 O 0 Education V o O 0 o O O Involvement with Child's Family 0 ./ O o o 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'A ❑ 2 ❑ 2'A ❑ 3 ❑ 3'A 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A 'IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk B /Oa Deputy C rk to th Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Baker, Elissa 2613 15th Ave Ct Greeley, CO 80634 B qutyk, 6)./6ctitt- 8 Weld County Addendum to the CWS-7A aa9-/?77 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date 1 a - ell by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Beasley, Travis and Sarah, Provider ID#1552607, 840 Grandview Meadows Dr. #A101, Longmont, CO 80503, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 v?o69 -R75< 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTESJ: Weld County Clerk to th Deputyerk to th Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature PROVIDER AUG 0 5 2009 Beasley, Travis and Sarah 840 Grandview Meadows Dr. #A101 Longmont, CO 80503 By: By: It' 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Beasley, Travis and Sarah and the 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 greement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1552607. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the C WS-7ij.,_azr but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A .4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: Du One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month ❑3%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month 02%) Once a week 03) 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 ❑1) Less than a '/2 hour per day 011/2) '/z hour a day 02) 1 hour a day 02 %) 1'/r2 hours per day 03) 2%r3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week ❑1'A) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑ 1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%,) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%:) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that ap m l to this child. O 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 0 O O O Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a iply to this child ❑ 0 0 ❑ 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation 0 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 ❑ 1 ❑ 1'h ❑ 2 ❑ 21 ❑ 3 ❑ 3'/ 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 112 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A•e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1.120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board /0Tht4S By:��-yJi9 Deputy Cl • rk tot c Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Beasley, Travis and Sarah 840 Grandview Meadows Dr. #A101 Longmont, CO 80503 By: By: ,a u? L 8 Weld County Addendum to the CWS-7A & -4'75z INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, & ao - 0 % by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Burden, Craig and Lea, Provider ID#1552261, 2203 A Street, Greeley, CO 80631, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 oxe 9 -/f7' H1. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County, Cler By: Deputy erk to thieoartz Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: pp Chair Signature AUG 0 5 2009 PROVIDER Burden, Craig and Lea 2203 A Street Greeley, CO 80631 3 oa'9-/d?7 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Burden, Craig and Lea and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this a0 day of auz+C. , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1552261. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWW:6n _,,J2)2 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 031/2) 7 round trips or more Comments: ❑1) One round trip a week 011/2) 2 round trips a week ❑2%a) 5 round trips a week 03) 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 02) Three times a month ❑3'%) Three times a week or more Comments: On Once a month 01%) Two times month ❑2%:) Once a week 03) 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? 0 Basic Maint.) No educational requirements 01) Less than a'h hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 %) 1'/i-2 hours per day 03) 2%:-3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours ❑39:) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 031/2) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1%:) 5 to 7 hours per week ❑21) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) OBasic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3/) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DIN NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that apply to this child. 0 0 0 0 0 0 Verbal or Physical Threatening 0 Destructive of Property/Fire Setting Stealing O Self -injurious Behavior Substance Abuse O 0 Presence of Psychiatric Symptoms/Conditions 0 0 0 O 0 0 Enuresis/Encopresis 0 Runaway 0 Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 0 0 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 ❑ 11/2 ❑ 2 ❑ 2'% ❑ 3 ❑ 3% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) County Basic Maintenance Rate 1 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $29.59 2 1(2 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) 3 $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES B Deputy Cl'6rk to the`IN& Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Ii By: Chair Signature AUG 0 5 2009 PROVIDER Burden, Craig and Lea 2203 A Street Greeley, CO 80631 8 Weld County Addendum to the CWS-7A &v9 —/J275 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date _ L,' I by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Carter, Jeremy and Susan, Provider ID#1556173, 3332 W 35th St, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate gthe development of the Family Service Plans for children in placement, including visits wilgtheir parents, siblings, and relatives, or transition to another foster care facility. ""- 5. To maintain approved standards of care as set by the State Department of Human Sgrvices. 6. To keep confidential the information shared about the child and his/her family. �= N 7. Not to accept money from parents or guardians. CO 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 07a' 9 -AW 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4: To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature AUG 0 5 2009 PROVIDER Carter, Jeremy and Susan 3332 W 35th St Greeley, CO 80634 By: . .L XZ \ Ck-CLIt 1 By. 3 0,2009 -a7X WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Carter, Jeremy and Susan and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this \ day of . 'X.., .. , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1556173. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A ate`}-/P7y but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A . 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week ❑1%z) 2 round trips a week ❑2%z) 5 round trips a week 03) 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 ❑2) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month ❑1'/) Two times month 02%) Once a week 03) 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 ❑1) Less than a''/z hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 %z) 1'/z-2 hours per day 03) 2%z-3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week ❑1%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 031/2) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week ❑3%z) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1'/z) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/z) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) Dl) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. 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 0 0 0 0 0 0 0 0 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 0 0 ❑ 0 0 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 ❑ 1 ❑ 11/2 ❑ 2 ❑ 21/2 ❑ 3 ❑ 31/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 11-14...$18.05/da $549/month Ave 15-21...$19.27/da $586/month + Res. ite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Cl Deputy C - to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Carter, Jeremy and Susan 3332 W 35th St Greeley, CO 80634 By: LLLU.Lth B 8 Weld County Addendum to the CWS-7A`/ ry79 t INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT ✓G 1. THIS CONTRACT AND AGREEMENT, made this date 7/ /O 9 by and betty the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of mss, the Weld County Department of Human Services, hereinafter called "County Department" and, 6 Corliss, Wade and Loni, Provider ID#1547483, 26649 CR 60 1/2, Greeley, CO 80631, �> hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 old -/Y'7/ 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Corliss, Wade and Loni 26649 CR 60 1/2 Greeley, CO 80631 3 d666; -/P7/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Corliss, Wade and Loni and the Weld County Department of Human Services for the period from July 1, 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 o t Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1547483. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the C3-21)9_ C but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P I. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week ❑1''/) 2 round trips a week O2%) 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 O3%) Three times a week or more Comments: 01) Once a month 01%) Two times month ❑2%:) Once a week O3) 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? O Basic Maint.) No educational requirements O2) 1 hour a day O3%) More that 3 hours per day Comments: ❑ 1) Less than a ''/I hour per day ❑ 1'%,) '/z hour a day O2 %) 1'/:-2 hours per day O3) 2'h-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week O3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) Du Less than 4 hours per month O2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. 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 ❑ ❑ ❑ ❑ ❑ ❑ ■ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensi of conditions which create the need for services that a . . l to this child. Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ 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 ❑ 1 ❑ 11/4 ❑ 2 ❑ 2'// ❑ 3 ❑ 3'/= 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emerge ncy Rate (30 day max) Effective 7/1/2008 Aqe 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Cler By: Deputy -rk to t Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: air Signature AUG 0 5 2009 PROVIDER Corliss, Wade and Loni 26649 CR 60 1/2 Greeley, CO 80631 By: (4010 //i0 BY: i-J 8 Weld County Addendum to the CWS-7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7 /j /09 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Cowper, Michael and Alecia, Provider ID#1526756, 509 N Sholdt Dr, Platteville, CO 80651, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 1'1. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk By: Deputy erk to t e Board Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: hair Sign —7 ure eAUG 0 5 2009 PROVIDER Cowper, Michael and Alecia 509 N Sholdt Dr Platteville, CO 80651 By: Bv: 3 ,7?ooq- /c 77 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Cowper, Michael and Alecia and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of / , 2009, are added to the referenced Agreement. Except as modified hereby, all terms t Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1526756. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, t Weld County Addendum to the 4 -/9/7 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, en -or, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? DBasic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. ❑3'/) 7 round trips or more Comments: ❑1) One round trip a week ❑1%) 2 round trips a week O 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 O3%) Three times a week or more Comments: ❑ 1) Once a month 01%) Two times month O2%) Once a week O3) 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 ❑1) Less than a %2 hour per day 01%) '/3 hour a day O2) 1 hour a day O2 A) 1'h-2 hours per day O3) 2'/r3 hours per day ❑3'A) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑ 1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) O Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A S -7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a . . 1 to this child. 0 0 0 ❑ 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 0 Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. 0 0 0 ❑ 0 0 0 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 0 Education Involvement with Child's Family 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2'A ❑ 3 ❑ 31/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) A.e 11-14...$18.05/da $549/month Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to - : 'ard WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES B Deputy erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: By: Chair Signature AUG 0 5 2009 PROVIDER Cowper, Michael and Alecia 509 N Sholdt Dr Platteville, CO 80651 8 Weld County Addendum to the CWS-7A 09 67—,��y INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 6 -/ 9 - O9 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Dietz, Bill and Wilma, Provider ID#8635, 21257 Hwy14, Ault, CO 80610, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 079 -/4'7'/ c '11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. r- ATTEyT: Weld t»ountyjCler, te(i aarrti? Deputy CCterk to the Bba?d. Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature AUG 0 5 2009 PROVIDER Dietz, Bill and Wilma 21257 Hwy14 Ault, CO 80610 3 c)m9 - /c'7, WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Dietz, Bill and Wilma and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this /9 day of (o , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#8635. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS- A but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3%z) 7 round trips or more Comments: ❑l) One round trip a week ❑1%) 2 round trips a week ❑2%z) 5 round trips a week 03) 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 02) Three times a month ❑3'/z) Three times a week or more Comments: 01) Once a month ❑i% Two times month 02%) 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 ❑1) Less than a''/z hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 %) 1'A-2 hours per day 03) 2'A-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week ❑1%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 011/2) 5 to 7 hours per week ❑2%z) 11 to 15 hours per week 03) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 011/2) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY MIS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a . • 1 to this child. ny3 0 0 0 ❑ 0 0 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 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Inappropriate Sexual Behavior Disruptive Behavior 0 0 0 0 0 0 0 O O 0 O 0 O O Delinquent Behavior 0 O O 0 0 0 O Depressive -like Behavior 0 O O O 0 O O Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) 0 0 0 O 0 O 0 Emancipation 0 O 0 O O O O Eating Problems O 0 0 O O 0 O Boundary Issues O 0 o o 0 O o Requires Night Care 0 0 0 0 o 0 0 Education 0 O O o 0 o O Involvement with Child's Family O 0 o 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2% ❑ 3 ❑ 31/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4-$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1.120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Cle, .. • - :oard WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES B Deputy . •rk to the Boatel Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Dietz, Bill and Wilma 21257 Hwy14 Ault, CO 80610 By: By: 8 Weld County Addendum to the CW_S-7A�, j p 77' INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date 7//A? by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Downey, John and Donna, Provider ID#1551054, 3826 W. 8th Street, Greeley CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 a -/g74 '11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES B Chair Signature AUG 0 5 2009 PROVIDER Downey, John and Donna 3826 W. 8th Street Greeley CO 80634 By: By: 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Downey, John and Donna and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The follgving provisions, made this I day of , 2009, are added to the referenced Agreen &t. Except as modified hereby, all terms of a greement remain unchanged. a GENEtAL PROVISIONS 1.County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1551054. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 -7A Weld County Addendum to the S -7A but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week B2) 3-4 round trips a week. 3%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week O2%) 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 63)Threetimes a month %) Three times a week or more Comments: 01) Once a month 01%) Two times month O2%) Once a week O3) 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 ❑2) 1 hour a day O3%) More that 3 hours per day Comments: ❑ 1) Less than a %z hour per day' 1 %) '/3 hour a day O2 %) 1'/r2 hours per day 3) 2'A-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 14 hours per week 0 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? Py Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) (�iBasic Maint.) Face-to-face contact one time per month with child and no crisis intervention. J" (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month 4-8 hours per month O3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑iN4 ❑ ❑ ❑ Destructive of Property/Fire Settingfa❑ ❑ ❑ ❑ ❑ ■ Stealing p ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious Behavior .. ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ • ■ ■ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑—t3❑ Enuresis/Encopresis 0 ❑ ❑ ❑ ❑ ❑ ■ Runaway ❑ ❑ ❑ ❑ ❑ • Sexual Offenses tzi ❑ ❑ ❑ ❑ ❑ ❑ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Inappropriate Sexual Behavior ❑ ❑ / ❑ ❑ ❑ • Disruptive Behavior ❑ ❑ ❑ ❑ ❑ • Delinquent Behavior ❑ ❑ ❑ ❑ S ❑ • Depressive -like Behavior ❑ ❑ ❑ ❑ ❑,JI1❑ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑91❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ ■ ■ Eating Problems Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care 7 ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ • Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'h ❑ 2 ❑ 2'h I( 3 ❑ 3'h 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Ase 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 11-14...$18.05/da $549/month Ase 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Cler B erk to the Board Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Downey, John and Donna 3826 W. 8th Street Greeley CO 80634 8 Weld County Addendum to the CWS-7A &cV9- 427', INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7// J0'1 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Fisher, Matthew and Claire, Provider ID#1532312, 5022 W 2nd St Rd, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 &009-/479 To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 • '4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTF$T: Weld County Clerk to t B Deputy C =rk to the EOOrd';'. Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: PROVIDER Fisher, Matthew and Claire 5022 W 2nd St Rd Greeley, CO 80634 Chair Signature AUG 0 5 2009 By: C X nip/ By: VriN 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Fisher, Matthew and Claire and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms ohAgreement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1532312. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS- /4,77y but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A S -7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week ❑1%) 2 round trips a week O2%) 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 O3%) Three times a week or more Comments: ❑l) Once a month 01%) Two times month ❑2%) Once a week O3) 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 ❑l) Less than a''/3 hour per day 01%) %z hour a day ❑2) 1 hour a day O2 %) l'A-2 hours per day O3) 2%r3 hours per day ❑3%z) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑l) Less than 5 hours per week DvA) 5 to 7 hours per week O2) 8 to 10 hours per week ❑2'A) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: ❑l) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) Dl) Less than 4 hours per month O2) 4-8 hours per month O3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 0 0 ❑ 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 0 Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a.ply to this child 0 0 0 ❑ 0 0 0 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 ❑1 ❑ 11/4 ❑ 2 ❑ 2A ❑ 3 ❑ 3'h 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 0-10...$16.32/da $496/month A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Res. ite Care $.66/da $20/month $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) Effective 7/1/2008 $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Deputy ' erk to Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 7009 PROVIDER Fisher, Matthew and Claire 5022 W 2nd St Rd Greeley, CO 80634 By: c kcy- By: 8 Weld County Addendum to the CWS-7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7 1,2m by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Gerardy, Jerry and Priscilla, Provider ID#1530549, 3408 Cody Ave, Evans, CO 80620, hereinafter called 'Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Serves. 6. To keep confidential the information shared about the child and his/her family. N.) 7. Not to accept money from parents or guardians. D 8. Not to make any independent agreement with parents or guardians. .f 9. Not to release the child to anyone without prior authorization from the Department. Cr 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 . To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. Deputy Clc 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 AUG 0 5 2009 PROVIDER Gerardy, Jerry and Priscilla 3408 Cody Ave Evans, CO 80620 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Gerardy, Jerry and Priscilla and the Weld County Department of Human Services for the period from July 1, 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 h Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1530549. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A a 2—/J74/ but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The tcim "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A • 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week O2%) 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 O3%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month O2%) Once a week O3) 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 ❑1) Less than a %z hour per day 01%) '/z hour a day ❑2) 1 hour a day O2 %) 1'/z-2 hours per day O3) 2'/z-3 hours per day O3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8 to 10 hours per week ❑2%z) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3 %z) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond a¢e appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. ❑2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a . . ly to this child. 0 ❑ 0 0 D Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior 0 0 Substance Abuse Presence of Psychiatric Symptoms/Conditions 0 0 Enuresis/Encopresis Runaway Sexual Offenses 0 0 0 0 0 0 5 Weld County Addendum to the CWS-7A S -7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a . . 1 to this child. Inappropriate Sexual Behavior 0 0 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 ❑ 11/4 ❑ 2 ❑ 2'h ❑ 3 ❑ 31/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk t. :oard WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: By: Chair Signature AUG 0 5 2009 PROVIDER Gerardy, Jerry and Priscilla 3408 Cody Ave Evans, CO 80620 8 O -/('79 Weld County Addendum to the WS -7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date (2-24 - O`i by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Goodman, Bob and Katie, Provider ID#1552796, 8134 Louden Circle, Windsor, CO 80528, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. t 02cb9- /87 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk B Deputy k to 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 PROVIDER AUG 0 5 2009 Goodman, Bob and Katie 8134 Louden Circle Windsor, CO 80528 By: (✓.�n By: ` yLll1. 3 &(≥99- tq WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Goodman, Bob and Katie and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this -2 lJ day of 3 o.r_ , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1552796. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 46 of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. 1 Weld County Addendum to the CWS-7A 9cc9 -/P 7V C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FID0S). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: I . To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A S -7A 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A P 1. WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: 01) One round trip a week 01%) 2 round trips a week ❑2'A) 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%x) Three times a week or more Comments: ❑1) Once a month 01%) Two times month ❑2'/) Once a week O3) 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 01) Less than a %z hour per day 01%) '/ hour a day ❑2) 1 hour a day O2 %) 1'/r2 hours per day O3) 2%r3 hours per day O3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'/) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%s) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A S -7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a. • I to this child. 0 0 0 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting 0 Stealing Self -injurious Behavior 0 Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway 0 0 Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that ap • 1 to this child. Disruptive Behavior Delinquent Behavior Depressive -like Behavior O Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) O 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 ❑ 1 ❑ 1 Yz ❑ 2 ❑ 2% ❑ 3 ❑ 3% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Goodman, Bob and Katie 8134 Louden Circle Windsor, CO 80528 8 Weld County Addendum to the CWS-7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7an°, 7.7) z.oc fl by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Helmer, Sara, Provider ID#1547292, 3000 W 19th St, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 ;j1Q7-/S)%1/ 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County, Clerk to B Deputy d"erk to the Bbprd'd- Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: / Chair Signature AUG 0 5 2009 PROVIDER Heimer, Sara 3000 W 19th St Greeley, CO 80634 By: C t.A. ct f— l 11\-9 tr 3 roc) 9-/S'7y WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Heimer, Sara and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this 2 day of a ti P , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1547292. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: I . To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A '4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: 01) One round trip a week 01%) 2 round trips a week ❑2%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month ❑1%) Two times month 02%) Once a week 03) 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 ❑1) Less than a''/z hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 %) 1'/2-2 hours per day 03) 2''/-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 011/2) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours ❑3%x) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 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.) Dl) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the C W S-7, WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a,ply to this child. ❑ 0 0 ❑ 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway 0 Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. Disruptive Behavior Delinquent Behavior Depressive -like Behavior 0 Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care Education 0 Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2A ❑ 3 ❑ 3'h 6 Weld County Addendum to the CWS-7 WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS- IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board c� Deputy o' erk to t r Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature PROVIDER Heimer, Sara 3000 W 19th St Greeley, CO 80634 By: XLicc AUG 0 5 2009 u'YI.Q r rn/,....'f 8 Weld County Addendum to the CWS-7A _0 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7Ii/D1 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Lewis, David and Connie, Provider ID#1523277, 2904 42nd Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 ,A700 417 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld Gountvt Clerk to th B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature.. Q 5 2009 PROVIDER Lewis, David and Connie 2904 42nd Ave Greeley, CO 80634 By: By: 3 9nng- /t'7 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Lewis, David and Connie and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of 2009, are added to the referenced Agreement. Except as modified hereby, all terms o th Agreement remain unchanged. GENERAL PROVISIONS County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1523277. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A %�j 2&'9- O c but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A S -7A 4, 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week ❑1%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month ❑3%:) Three times a week or more Comments: ❑l) Once a month 01%) Two times month 02%) Once a week 03) 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 ❑1) Less than a''/3 hour per day ❑1'%)'h hour a day 02) 1 hour a day 02 %) 1'/r2 hours per day 03) 2'/2-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours ❑3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a . . 1 to this child. ❑ 0 ❑ ❑ 0 0 0 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 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. 0 0 0 ❑ 0 0 0 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 ❑ 1 ❑ 1'h ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'/ 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Age 0-10...$16.32/day ($496/month) Ate 11-14...$18.05/da $549/month Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: ChairrSignature AUG 0 5 2009 PROVIDER Lewis, David and Connie 2904 42nd Ave Greeley, CO 80634 8 Weld County Addendum to the CWS- L l INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date Jane v11- Z 009 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Maronek, Dennis and Patricia, Provider ID#1520627, 4860 Eagle Crest Blvd, Firestone, CO 80504, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 ,?cc9 16'71 To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to th By: aAs, Deputy g'' rk to the Boa 4 Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN ERVICES Chair Signature AUG Q 5 2009 PROVIDER Maronek, Dennis and Patricia 4860 Eagle Crest Blvd Firestone, CO 80504 3 so)ci-/6'7c2 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Maronek, Dennis and Patricia and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this:2/ day of J or) -e. , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1520627. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4`h of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the C(;41,0)9'' „5 Jed,p _/779 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FID0S). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week ❑1%:) 2 round trips a week ❑2%) 5 round trips a week 03) 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 02) Three times a month 031/2) Three times a week or more Comments: 01) Once a month ❑1'/) Two times month ❑2'%:) Once a week 03) 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 ot special education plan? ❑ Basic Maint.) No educational requirements 01) Less than a %z hour per day 01%) '/z hour a day 02) 1 hour a day 02 %) 1'/r2 hours per day 03) 2'/2-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week ❑1/) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%x) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑3'%:) 21 or more hours per week Comments: ❑ 1) 3 to 4 hours per week 011/2) 5 to 7 hours per week 02%2) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3/) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the CWS- WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. 0 0 0 ❑ 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions O 0 O Enuresis/Encopresis Runaway Sexual Offenses O O 0 O 0 O 0 O 5 Weld County Addendum to the CWS- S- BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. Inappropriate Sexual Behavior 0 0 0 0 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation 0 Eating Problems 0 Boundary Issues 0 Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/i ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'h 6 Weld County Addendum to the CWS- S- WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Deputy Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: • Chair Signature AUG 0 5 2009 PROVIDER Maronek, Dennis and Patricia 4860 Eagle Crest Blvd Firestone, CO 80504 By: By: R Weld County Addendum to the CWS-7A &ci>- /S'79 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS CONTRACT AND AGREEMENT, made this date, 09 by and between the Board of Weld County Commissioners, sitting as the Board of / ocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Mauk, James and Harriett, Provider ID#1537621, 3620 Dilley Circle, Johnstown, CO 80534, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 02(2')9-/S27Y 1f. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk t Deputy rk to the B 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 PROVIDER AUG 0 5 2009 Mauk, James and Harriett 3620 Dilley Circle Johnstown, CO 80534 3 ,9"& - /cP73 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Mauk, James and Harriett and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms o t Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1537621. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, t Weld County Addendum to the CWS-7A ae9—/k'j" but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4.. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3%) 7 round trips or more Comments: ❑1) One round trip a week ❑1 %n) 2 round trips a week 02%) 5 round trips a week ❑3) 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 ❑2) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month ❑1/) Two times month 02%) Once a week 03) 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 ❑1) Less than a %3 hour per day 011/4) 'A hour a day 02) 1 hour a day 02 'A) 11/2-2 hours per day 03) 2'/-3 hours per day ❑3'%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week ❑1%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1%n) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 021/2) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a to this child. 0 ❑ ❑ ❑ 0 0 0 Verbal or Physical Threatening El Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse 0 0 Presence of Psychiatric Symptoms/Conditions 0 Enuresis/Encopresis Runaway El Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. Disruptive Behavior 0 Delinquent Behavior O Depressive -like Behavior Medical Needs ( If condition is rated "severe", please complete the Medically fragile NBC) O Emancipation Eating Problems Boundary Issues 0 0 0 O 0 0 0 Requires Night Care 0 Education O Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1' ❑ 2 ❑ 21 ❑ 3 ❑ 31/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Ase 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) Effective 7/1/2008 $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7 IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Bv: Deputy ' erk to Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES B WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature PROVIDER Mauk, James and Harriett 3620 Dilley Circle Johnstown, CO 80534 By: BY:�_,� rt 8 Weld County Addendum to the CWS-7A 070C9—/'7�f INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7 /1) D9 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, McCreery, James and Tammy, Provider ID840215, 120 Maple Ave, Eaton, CO 80615, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Service 6. To keep confidential the information shared about the child and his/her family. L._ C 7. Not to accept money from parents or guardians. ry a- 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. R 10. To allow representatives of the County Department to visit the foster home and to see the c4iild at any reasonable time. 1 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County, Clerk B Deputy erk to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: v�G PROVIDER McCreery, James and Tammy 120 Maple Ave Eaton, CO 80615 Chai(Signature AUG 0 5 2009 3 aoo9 -'J'79 ti WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between McCreery, James and Tammy and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this day of a ,(k , 2009, are added to the referenced Agreement. Except as modified hereby, all terms t }� Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#40215. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A o'a 2 -if 7' but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3%z) 7 round trips or more Comments: ❑1) One round trip a week El 1%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: 01) Once a month 01%) Two times month 02%) Once a week 03) 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 ❑1) Less than a''/z hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) 1'/z-2 hours per day ❑3) 2%z-3 hours per day ❑3%z) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%z) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child. 0 0 0 ❑ ❑ 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing 0 Self -injurious Behavior Substance Abuse 0 Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway 0 Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a . . 1 to this child Inappropriate Sexual Behavior Disruptive Behavior 0 0 0 ❑ 0 0 Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues 0 Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 11A ❑ 2 ❑ 2% ❑ 3 ❑ 3'% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: hair Signature AUG 0 5 2009 PROVIDER McCreery, James and Tammy 120 Maple Ave Eaton, CO 80615 8 Weld County Addendum to the CW A , ,(27 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, cJune 219 ZOC? by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, McGee, Donna, Provider ID#1539853, 1649 31st Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 07009-417 11: To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. ' To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTESZ: Weld County clerk t Deput -/ lerk to the By: 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: PROVIDER McGee, Donna 1649 31st Ave Greeley, CO 80634 hair Signature AUG n 5 2009 By: Q. -klo By: 3 02c0- 79 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between McGee, Donna and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this 2 Co day of j1. , RjL , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1539853. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CW 7A but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3''/) 7 round trips or more Comments: W]1) One round trip a week ❑1%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month ❑1%) Two times month ©2'/) Once a week 03) 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? 4iBasic Maint.) No educational requirements O1) Less than a''/z hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 %) 1'/-2 hours per day 03) 21/2-3 hours per day ❑3'/) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed [31) Less than 5 hours per week ❑1%) 5 to 7 hours per week $j2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ®1) 3 to 4 hours per week ❑1%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. '1 /) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑l) Less than 4 hours per month 02) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a to this child. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ < ❑ ❑ Kerb or Physical ❑ ❑ ❑ [ ❑ ❑ ❑ O n \ �� iw A F 1 eatening Destructive of Property/Fire Setting ❑ S ❑ ❑ ❑ ❑ ■ Stealing 4❑ ❑•• ❑ ❑ Self -injurious Behavior ❑ IA ❑ ❑ ❑ ❑ ■ Substance Abuse 4p ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis a ❑ ❑ ❑ ❑ ❑ ❑ Runaway 41 ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ w`�Iandd J t} —5 (Rs 04 a 5 Weld County Addendum to the CWS-7A S -7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. Inappropriate Sexual Behavior Disruptive Behavior 0 0 0 0 0 0 o w aid- evi-f p Phi VatS4r S94 0 Delinquent Behavior 0 0 0 Depressive -like Behavior 0 0 Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) 0 0 0 0 0 0 Emancipation F 0 0 0 Eating Problems 0 Boundary Issues 0 0 0 0 P.dcu- no l4 iL O0rnfl�l Requires Night Care 0 0 0 Education 0 0 0 0 0 Involvement with Child's Family 0 0 0 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 . l y4 1'A ❑ 2 ❑ 2'/ ❑ 3 ❑ 3t/z 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) County Basic Maintenance Rate 1 Aqe 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Aqe 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $29.59 21/2 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) 3 $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to th B Deputy CXerk to the Boa Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN ERVICES Chair Signature AUG 0 5 2009 PROVIDER McGee, Donna 1649 31st Ave Greeley, CO 80634 By: „.\-m 8 Weld County Addendum to the CWS-7A a 9 -/Fly INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, OfP 2.11 VI by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Mellmen, Jeffrey and Letha, Provider ID#1547484, 352 Laurel Ave, Eaton, CO 80615, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits withjeir parents, siblings, and relatives, or transition to another foster care facility. c 5. To maintain approved standards of care as set by the State Department of Human ServW6es. N cr 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 t)2a'9- /4277 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld Clerk t Glr LA/ Deputy B 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,AUG 0 5 2009 PROVIDER Mellmen, Jeffrey and Letha 352 Laurel Ave Eaton, CO 80615 3 ,9009-/V*y WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Mel!men, Jeffrey and Letha and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this 7,0 day of i UNF , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1547484. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4°' of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A � _ /J7// but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FID0S). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ®2) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑ I) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 2) Three times a month 3%) Three times a week or more Comments: ❑ 1) Once a month ❑1%) Two times month 02%) Once a week 03) 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? RI Basic Maint.) No educational requirements ❑1) Less than a %z hour per day ❑1%)'h hour a day 02) 1 hour a day 02 %) 11/2-2 hours per day 03) 2'/:-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ® Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours ❑3'/,) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: Z1) 3 to 4 hours per week 011/2) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month 02) 4-8 hours per month ®3) 9-12 hours per month 4 Weld County Addendum to the CWS-' WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a to this child. ® 0 0 0 Verbal or Physical Threatening K] Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 0 tP 0 0 Runaway Sexual Offenses 5 Weld County Addendum to the CWS- BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. Disruptive Behavior Delinquent Behavior O Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) isd Emancipation Eating Problems Boundary Issues Requires Night Care Egi Education tz Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'// ❑ 2 ❑ 21 ❑ 3 ❑ 3'h 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the : sard WELD COUNTY BOARD OF SOCIAL ,atetki SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN b� '\ SERVICES By: A4 - Deputy C ,' k to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Mellmen, Jeffrey and Letha 352 Laurel Ave Eaton, CO 80615 By: By: 8 Weld County Addendum to the CWS-7 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7//09 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Mena, David and Marie, Provider ID#1510691, 2905 41st Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 `11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 .4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk Deputy Merk to the By: 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: Ch it Signature PROVIDER Mena, David and Marie 2905 41st Ave Greeley, C,Q 80¢134 r AUG 0 5 2009 3 07069- /d'7' WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Mena, David and Marie and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms o th Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1510691. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before paynnit will be release to Provider. t_ c 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. ty 5. All reimbursement requests shall: �^ A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the C239, a 7i- but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A •4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week N2) 3-4 round trips a week. 3'/2) 7 round trips or more Comments: 01) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month 02%) Once a week 03) 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 2) 1 hour a day 03%) More that 3 hours per day Comments: 01) Less than a''/a hour per day 01%) 1/2 hour a day 02 %) 1'/-2 hours per day 03) 2'/-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1/) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a . . 1 to this child. 0 0 0 ❑ 0 0 0 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 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a Disruptive Behavior Delinquent Behavior CI Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems CI Boundary Issues CI Requires Night Care Education O Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1/ ❑ 2 ❑ 2A ❑ 3 ❑ 3%2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Deputy �erk to th Boar; 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 B Chair Signature AUG 0 5 2009 PROVIDER Mena, David and Marie 2905 41st Ave Greeley, O 8 634 Byr By: 8 Weld County Addendum to the CWS-7A O7O6,g-/?7 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7// 09 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Moore, Earl and Patricia, Provider ID#1517579, 135 Poplar St, Lochbuie, CO 80603, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 6;e09- /1)75/ To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld Clerk to B Deputy.'erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES B Chair Signature PROVIDER AUG 0 5 7.nn) Moore, Earl and Patricia 135 Poplar St Lochbuie, CO 80603 • By:(Ltf/�c�tn By�C" 3 0,96x59 -1S7 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Moore, Earl and Patricia and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this / day of Agreement. Except as modified hereby, all terms oftho/Agreement remain unchanged. GENERAL PROVISIONS , 2009, are added to the referenced 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1517579. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limi9d to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Ay payment for specialized services not authorized in writing may be denied. o- 5. All reimbursement requests shall: -o tai A. Be submitted in a format approved by the County. If submitted in an unapap- ved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A 32OO% -7P7y but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A S -7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. ❑3'A) 7 round trips or more Comments: ❑1) One round trip a week 01%) 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 Comments: ❑1) Once a month 01%) Two times month O2%) Once a week O3) 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? O Basic Maint.) No educational requirements ❑2) 1 hour a day O3%) More that 3 hours per day Comments: ❑ 1) Less than a 'h hour per day ❑ 1'%) '/z hour a day O2 '/) 1'/:-2 hours per day O3) 2'h-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours ❑3'h) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1') Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%:) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 01) Less than 4 hours per month O2) 4-8 hours per month O3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that apply to this child. 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 ❑ ❑ ❑ ❑ ❑ ❑ ■ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..l to this child Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Delinquent Behavior ❑ ❑ ❑ ❑•❑ ❑ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ • Emancipation ❑•❑ 0 ❑ ❑ 0 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 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2'A ❑ 3 ❑ VA 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) County Basic Maintenance Rate 1 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 112 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $29.59 2 1/2 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) 3 $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 3 112 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board � 14# B Deputy I'erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Moore, Earl and Patricia 135 Poplar St Lochbuie, CO 80603 8 Weld County Addendum to the CWS-7A 07 _/,7y INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 75, 1. THIS CONTRACT AND AGREEMENT, made this date, 7/109 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of c?.4) the Weld County Department of Human Services, hereinafter called "County Department" and, Munnelly, John and Heidi, Provider ID#1523563, 291 Columbus St, Windsor, CO 80550, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 ??©D y - 4S97y 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To.give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. Deputy erk to the 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 PROVIDER Munnelly, John and Heidi 291 Columbus St Windsor, CO 80 By: By: 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Munnelly, John and Heidi and the 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 6'f t Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1523563. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A eto%-/d7% but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. • 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A P 1. WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03 V2) Three times a week or more Comments: 01) Once a month 01%) Two times month ❑2%) Once a week 03) 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 01) Less than a'' /z hour per day 01%) %z hour a thy 02) 1 hour a day 02 %) 1'/2-2 hours per day 03) 2'/1-3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 011/2) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3X) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. 0 0 ❑ 0 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 0 Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 0 0 0 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior 0 Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) 0 Emancipation Eating Problems Boundary Issues Requires Night Care Education 0 Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/ ❑ 2 ❑ 2'/2 ❑ 3 ❑ 3'h 6 Weld County Addendum to the CWS- WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 31/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 0-10...$16.32/da $496/month A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS IN. WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Deputyerk to th:,9br Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Sign'dtt re AUG 0 5 2009 PROVIDER Munnelly, John and Heidi 291 Columbus St Windsor, CO 805 By: By: 8 Weld County Addendum to the CWS-7A o?Cei-/(1-) f INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, Le ' 09 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services; on behalf of the Weld County Department of Human Services, hereinafter called "County Departmtand, Pluma, Mike and Annette, Provider ID#35126, PO Box 34, Kersey, CO 80644, hereirra called "Provider." 2s 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until A June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and 2s agreement may be renewed at any time during the term of the valid facility certificate. This s contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 fi. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to the B /' Deputy lerk to the t Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: hair Sig ture AUG 0 5 2009 PROVIDER Pluma, Mike and Annette PO Box 34 Kersey, t♦O 81,644 By: By: ' �� 4 3 ��g_ /S27 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Pluma, Mike and Annette and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this ,;2), day of 3i,t,y , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#35126. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A q—/P7S but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A • 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: 01) One round trip a week 01%) 2 round trips a week ❑2%:) 5 round trips a week 03) 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 02) Three times a month ❑3'/:) Three times a week or more Comments: ❑1) Once a month 01%) Two times month 02%) Once a week 03) 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 ❑1) Less than a''/3 hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) 1'/:-2 hours per day 03) 2%r3 hours per day 031/2) More that 3 hours per thy Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed On Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1'/) 5 to 7 hours per week ❑2''/) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a ' ' 1 to this child. 0 0 ❑ 0 0 0 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 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a . . 1 to this child. Inappropriate Sexual Behavior Disruptive Behavior 0 0 0 ❑ 0 0 Delinquent Behavior El 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 ❑ 1 ❑ 11 ❑ 2 ❑ 21/2 ❑ 3 ❑ 3'/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) County Basic Maintenance Rate 1 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $29.59 2 1/2 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) 3 $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 3 1/2 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld �County y Clerk to the Board ike B Deputy ' erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: AUG 0 5 2009 PROVIDER Pluma, Mike and Annette PO Box 34 Kersey, CO 80644 IA-l)(16 By: By: %2 8 Weld County Addendum to the CWS-7A S -7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, J(AA I )� by and between the Board of Weld County Commissioners, sitting as the ard of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Preston, Daniel and Lisa, Provider ID#1548050, 611 Cornerstone Dr, Windsor, CO 80550, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to Deputy C By: 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 Chair Signature PROVIDER Preston, Daniel and Lisa 611 Cornerstone Dr Windsor, CO 80550 AUG 0 5 2009 By: )241 By: //X4 J�� ,413,--n- 3 02002-,S'7y WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Preston, Daniel and Lisa and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this ) iJtay of Z( , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1548050. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A .-D7irr9 —AP: but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A • 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 031/2) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month ❑3%:) Three times a week or more Comments: ❑l) Once a month ❑1%) Two times month 02%) Once a week 03) 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 Du Less than a %x hour per day 01%) ''A hour a day 02) 1 hour a day 02 %x) 1'/r2 hours per day 03) 21/2-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑l) Less than 5 hours per week ❑1%z) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 031/2) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) DBasic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1,A) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 021/2) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑l) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7 WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a to this child. 0 0 0 0 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting 0 Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 0 0 O 0 O 5 Weld County Addendum to the CWS-7 BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a.ply to this child. 0 0 0 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 ❑1 ❑ 1% ❑2 ❑ 2% ❑ 3 ❑3v 6 Weld County Addendum to the CWS-7 WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Ase 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 31/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-' IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to B WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Deputy Clerk to the Boar % '! `. Chair Signature AUG 0 5 2009 Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: PROVIDER Preston, Daniel and Lisa 611 Cornerstone Dr Windsor, CO 80550 By: AIM Pik% IDA. By: 7i,(4 C/ a 8 Weld County Addendum to the CWS-7A 021,)9-49 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES ham' AND „et FOSTER CARE FACILITY AGREEMENT TI 'CONTRACT AND AGREEMENT, made this date .7; tie_ rim ?C, S/ by and between Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of e Weld County Department of Human Services, hereinafter called "County Department" and, Purcella, Denise, Provider ID#1551571, 10656 Bald Eagle Circle, Firestone, CO 80504, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 :Do% /J' 7y 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTfST: Weld County CI•r B Deputy to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Purcella, Denise 10656 Bald Eagle Circle Firestone, CO 80504 71/ By:EroL LL;x 3 ,..)2609-4972/1 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Purcella, Denise and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this f'1 day of i-u pL , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS I . County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1551571. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the C W 7A but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FID0S). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A • 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week ❑2'A) 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 O3%) Three times a week or more Comments: 01) Once a month 01%) Two times month O2%) Once a week O3) 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 ❑1) Less than a'/z hour per day 01%) %: hour a day ❑2) 1 hour a day O2 %) 1'/r2 hours per day O3) 2%r3 hours per day O3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A S -7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a 1 to this child. 0 0 0 ❑ 0 0 0 Verbal or Physical Threatening 0 Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions 0 0 0 Enuresis/Encopresis 0 Runaway 0 0 0 Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. Disruptive Behavior Delinquent Behavior Depressive -like Behavior 0 0 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 ❑ 3t'/ 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) County Basic Maintenance Rate 1 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 1/2 4.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $29.59 2 1/2 4.66 Respite Care Total Rate = ($30.25 day/$920 month) 3 31/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-i IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES y: Chair Signature AUG 0 5 20A PROVIDER Purcella, Denise 10656 Bald Eagle Circle Firestone, CO 80504 By: 8 Weld County Addendum to the CWS-7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 71// 09 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Ramos, Julian, Provider ID#37631, 2604 49th Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 L.,(719j-/?77 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 '4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to 01495a d' 17 B Deputy C Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature PROVIDER Ramos, Julian 2604 49th Ave Greelev.,CO 80634 AUG 0 5 2009 3 �7c'9 -/x)79 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Ramos, Julian and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of Agreement. Except as modified hereby, all terms o Agreement remain unchanged. GENERAL PROVISIONS , 2009, are added to the referenced 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels dettA mined. 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 Weld County Certified Foster Care Home identified as Provider ID#37631. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A 17719—/�74 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3'/) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month ❑2%:) Once a week 03) 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 ❑2) 1 hour a day 03%) More that 3 hours per day Comments: ❑ 1) Less than a 'V2 hour per day 01%) %z hour a day 02 %) 11/2-2 hours per day 03) 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 ❑ 1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond ace appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one timeper month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a . . l to this child. Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ 0 • Disruptive Behavior ❑ ❑ ❑ ❑ ❑ • • Delinquent Behavior ❑ ❑ ❑ ❑ ❑ 0 ■ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑•❑ ❑ Emancipation ❑ ❑ ❑ ❑ ❑ ❑ • Eating Problems ❑ ❑ ❑IN ❑ II❑ 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 ❑ 1 ❑ 1/s ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'// 6 Weld County Addendum to the C WS -7P WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 Weld County Addendum to the CWS-7/ IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature AUG 0 5 2009 PROVIDER Ramos, Julian 2604 49th Ave Greeley, CO 80634 8 Weld County Addendum to the C,WS-7 /5 >i INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7///09 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Ransome, Christopher and Mary, Provider ID#1552605, 436 26th Ave Ct, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. I a&c259 /e'7y - 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTESJ: Weld Cqunty tvler to B Deputy -rk to fhe Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES B Chair Signature AUU 0 5 2009 PROVIDER Ransome, Christopher and Mary 436 26th Ave Ct Greeley, CO 80634 By: By: 3 c9U59— 4f 7y WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster,Care Services and Foster Care Facility Agreement (the "Agreement") between. Ransome, Christopher and Mary ' / and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms o th Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster caie home or if the child is placed in a County foster/adoption home as a pre -adoptive == placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designates as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1552605. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, <q Weld County Addendum to the CWS-7A 005'-/f 73 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑ Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month O 3%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month ❑2%:) Once a week 03) 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 m special education plan? 0 Basic Maint.) No educational requirements ❑2) 1 hour a day ❑3%x) More that 3 hours per day Comments: ❑1) Less than a''/z hour per day 01%) 1/2 hour a day 02 %) 1%r2 hours per day 03) 2%r3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%:) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the CWS- WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a 1 to this child. Aggression/Cruelty to Animals 0 0 0 ❑ 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions 0 0 0 Enuresis/Encopresis Runaway Sexual Offenses 0 0 0 0 5 Weld County Addendum to the CWS- BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a r r I to this child. Inappropriate Sexual Behavior 0 0 0 ❑ 0 0 0 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 ❑ 1 ❑ 1'// ❑ 2 ❑ 21/2 ❑ 3 ❑ 3'/ 6 Weld County Addendum to the CWS- WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) County Basic Maintenance Rate 1 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 1/2 rc,1 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $29.59 2 1/2 +$.66 Respite Care 4 Total Rate = ($30.25 day/$920 month) 3 $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 3 1/2 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County y Clerk to t � n 1 Gam( Deputy C irk to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: fi WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES 7 air Signature AUG 0 5 2009 PROVIDER Ransome, Christopher and Mary 436 26th Ave Ct Greeley, CO 80634 8 Weld County Addendum to the CWS-7A o?a39—/cr77 • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT n� '-I //. 1. THIS CONTRACT AND AGREEMENT, made this date, 7 I i IU / by and bef1e the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Rasmussen, Dennis and Diane, Provider ID#104555, 345 Gypsum Lane, Johnstown, CO 80534, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 a7CY3y-/d''7� 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to By: Deputy C - k to e Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Rasmussen, Dennis and Diane 345 Gypsum Lane Johnstown, CO 80534 By a ` CV — By: ,(0-Y - &72L44Q _ 3 dO09-/'77 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Rasmussen, Dennis and Diane and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms ofhe greement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#104555. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the WS -7A but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A •4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A P 1. WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week O2%) 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 ❑2) Three times a month ❑3%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month ❑2%) Once a week O3) 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 01) Less than a %z hour per day 01%) '/z hour a day O2) 1 hour a day O2 'A) 1'/r2 hours per day O3) 2'/2-3 hours per day O3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours ❑3''A) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2'%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%:) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0) Not needed or provided by another source (i.e. Medicaid) ❑l) Less than 4 hours per month O2) 4-8 hours per month O3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. 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 O O O O O O O O O O O O O O O O O O ❑ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a 0 y to this child. 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior 0 Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care 0 Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 Ell ❑ 11/2 ❑ 2 ❑ 2% ❑ 3 ❑ 3''/ 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Age 0-10...$16.32/day ($496/month) A.e 11-14...$18.05/da $549/month Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) Assessment/Emergency Rate (30 day max) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the : sard WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD E ��% COUNTY DEPARTMENT OF HUMAN .... % SERVICES B Deputy ' erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: By: Chair Signature AUG 0 5 2009 PROVIDER Rasmussen, Dennis and Diane 345 Gypsum Lane Johnstown, CO 80534 By: By:J -(a/YLc- rit,y t d _ 8 Weld County Addendum to the CWS-7A 07609l 751 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date OSV J4'4e 2001 by and between the Board of Weld County Commissioners, sitting as the Board of'Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Rothe, Terry and Marilyn, Provider ID#15169, 4115 W 20th St Rd, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. ta safely provide the 24 -hour physical care and supervision of each child until removed or until t6agreement is renewed. 3. TOeccept children only with the approval of the certifying/licensing agency. 4. Tocooperate fully with the County Department or its representatives, and participate in the dev pment of the Family Service Plans for children in placement, including visits with their pareTs, siblings, and relatives, or transition to another foster care facility. 5. To m'intain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 o?CY5y_/s)7y 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk By: Deputy "`erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: AA' Chai gnature AUG 0 5 2009 PROVIDER Rothe, Terry and Marilyn 4115 W 20th St Rd Greeley, CO 80634 By: By: 3 ca&Q59-/8%V , r WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Rothe, Terry and Marilyn and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made thisa p day of c, p e. , 2009, are added to the referenced Agreement. Except as modified hereby, all terms f the Agreement remain unchanged. GENERAL PROVISIONS County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#15169. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A -v v — /?7<i but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑l) One round trip a week ❑1%) 2 round trips a week ❑2%x) 5 round trips a week 03) 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 ❑2) Three times a month ❑3%a) Three times a week or more Comments: ❑l) Once a month 01%) Two times month ❑2'/:) Once a week 03) 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 ❑l) Less than a %I hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 '4) 1'/-2 hours per day 03) 2'h-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑I) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1'/,) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑l) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. 0 0 0 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 0 Runaway 0 Sexual Offenses 0 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child. 0 0 0 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe-, please complete the Medically fragile NBC) Emancipation 0 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 ❑1 ❑ 1% ❑ 2 ❑ 2% ❑ 3 ❑ 3'% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Aqe 0-10...$16.32/day ($496/month) Aqe 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Deputy ' erk to \, Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature' AUG 0 5 2009 PROVIDER Rothe, Terry and Marilyn 4115 W 20th St Rd Greeley, CO 80634 By: By: r‘4 8 Weld County Addendum to the CWS-7A (7a'`9-- /?7 r pr INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 42 lxi 01 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Sands, Corey and Amy, Provider ID#1555552, 2026 27th Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. S 5. To maintain approved standards of care as set by the State Department of Human Sews. c 6. To keep confidential the information shared about the child and his/her family. 0 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. W 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 o?069- At) 7f 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to th B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: air Signature AUG 0 5 2009 PROVIDER Sands, Corey and Amy 2026 27th Ave Greeley, CO 634 By: 3 (6209 -/P WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Sands, Corey and Amy and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this day of �1a' u_ , 2009, are added to the referenced Agreement. Except as modified hereby, all terms oo the Agreement remain unchanged. GENERAL PROVISIONS County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1555552. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A &IC9-i&'75 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: I . To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? DBasic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: On One round trip a week 011/4) 2 round trips a week ❑2'/o 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: On Once a month 01%) Two times month 02%) Once a week 03) 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 01) Less than a %3 hour per day ❑1%)'/2 hour a day 02) 1 hour a day 02 %) 11/2-2 hours per day 03) 2'/r3 hours per day ❑3%x) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to I0 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 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%z) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) 01) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7. WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a to this child. 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions 0 Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a . • I to this child. 0 0 0 0 ❑ 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 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 31/2 6 Weld County Addendum to the CWS-' WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS- S- IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, • month, and year first above written. ATTEST: Weld County Clerk t. • =ward WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES B Deputy k to the Bial#cf';i Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: By: ature AUG 0 5 2009 PROVIDER Sands, Corey and Amy 2026 27th Ave Greeley, CO 80634 8 Weld County Addendum to the CWS-7A 0? 9—/c'7 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, (p ' / ook2 I by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Sevestre, Lewis and Maureen, Provider ID#1551169, 1717 69th Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 a,7oo5c a 7 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEyT: Weld ountyjCler B Deputy ' erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Sevestre, Lewis and Maureen 1717 69th Ave Greeley, CO 80634 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Sevestre, Lewis and Maureen and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this / S' day of (JW7( , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1551169. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A a'Dd—/� but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3Y:) 7 round trips or more Comments: ❑1) One round trip a week ®1'%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: 01) Once a month 01%) Two times month ®2%:) Once a week 03) 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 2) 1 hour a day 03%) More that 3 hours per day Comments: ❑1) Less than a 1/2 hour per day ❑ 1%) '/z hour a day 02 %) 1'/r2 hours per day 03) 2'/2-3 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? 5;f Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week 0 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑ 1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month I ,2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. ❑ ❑ 0 0 0 Verbal or Physical Threatening 2 Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse 0 O 0 0 O Presence of Psychiatric Symptoms/Conditions 0 O 0 Enuresis/Encopresis Runaway O O 0 Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 Disruptive Behavior 0 Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) 0 Emancipation /P Eating Problems Boundary Issues Requires Night Care 0 Education p Involvement with Child's Family Cif CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ®tt ❑ 11z ❑ 2 ❑ 2% ❑ 3 ❑ 3% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the C W S- i • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature AUG 0 5 2009 PROVIDER Sevestre, Lewis and Maureen 1717 69th Ave Greeley, CO 80634 By: By. 8 Weld County Addendum to the CWS-7A S -7A 07C09 —/P/ INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT / 1. THIS CONTRACT AND AGREEMENT, made this date, ////01"/ by and betsa*. the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of CS the Weld County Department of Human Services, hereinafter called "County Department" and, Skeldum, William, Provider ID#16666, 5113 Saguaro Ct, Johnstown, CO 80534, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk B Deputy,#'erk to the t 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: PROVIDER Skeldum, William 5113 Saguaro Ct Johnstown, CO 80534 By: W V L 3 07009-/'7' WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Skeldum, William and the Weld County Department of Human Services for the period from July 1, 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 f Agreement remain unchanged. GENERAL PROVISIONS I . County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#16666. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, t Weld County Addendum to the CWS-7A 07009 —/P but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: I . To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY 9115 NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week ❑1/) 2 round trips a week 02%) 5 round trips a week ❑3) 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 02) Three times a month 03%) Three limes a week or more Comments: 01) Once a month 01%) Two times month 02%) Once a week 03) 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 On Less than a''/3 hour per day 01%) %x hour a day ❑2) 1 hour a day 02 %) 1' /r2 hours per day 03) 2%r3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 0 0 ❑ 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse 0 Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensit of conditions which create the need for services that a . . ly to this child. 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 O Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 21/2 ❑ 3 ❑ 31/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7 S-7. IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the B WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Deputy 'erk to the Board Chair Signature AUG 0 5 2009 Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: PROVIDER Skeldum, William 5113 Saguaro Ct Johnstown, CO 80534 By: ?ALL_ ke^'-- 8 Weld County Addendum to the CWS-7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT �I 1. THIS CONTRACT AND AGREEMENT, made this date, itJ - c i by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Slaughenhaupt, Gary and Grace, Provider ID#1544611, 30633 CR 78, Eaton, CO 80615, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 a>� - /d'75 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County lerk to the Deputy •%erk to the Bo Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair ignature AUG 0 5 2009 PROVIDER Slaughenhaupt, Gary and Grace 30633 CR 78 Eaton, CO 80615 3 �C�O�- %V7, WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Slaughenhaupt, Gary and Grace and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this 3'. ' day of .1',• ^e_ , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1544611. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A S-7Ap O2ctn_ /C/ but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month 02%) Once a week 03) 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 of special education plan? ❑ Basic Maint.) No educational requirements ❑1) Less than a '/2 hour per day 01%) '/z hour a day 02) 1 hour a day 02 %) 1'h-2 hours per day 03) 2%r3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedir bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%:) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 011/2) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 weld County Addendum to the CWS- WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that ap.ly to this child. 0 0 ❑ 0 0 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 0 5 Weld County Addendum to the CWS- BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a ' . ly to this child. Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ • 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 ❑ 1 ❑ 11 ❑ 2 ❑ 2Y/ ❑ 3 ❑ 3'/ 6 Weld County Addendum to the CWS- WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS, IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Sicature AUG 0 5 2009 PROVIDER Slaughenhaupt, Gary and Grace 30633 CR 78 Eaton, CO 80615 By: ✓ ' ?9 2 By: a al t I � r C 7 8 Weld County Addendum to the CWS-7A 62a59 /87i INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7 /) )D9 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Steitz, Daniel and Natalie, Provider ID#1546930, 1701 Elder Ave, Greeley, CO 80631, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 ooh /e75/ - 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4' To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: County Clerk to th i Deputy %erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature PROVIDER Steitz, Daniel and Natalie 1701 Elder Ave Greeley, CO 80631 i 0 By: By: AUG 0 5 2009 3 07002'- 497r WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Steitz, Daniel and Natalie and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of Agreement. Except as modified hereby, all terms oftle Agreement remain unchanged. GENERAL PROVISIONS , 2009, are added to the referenced 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1546930. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4`h of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A S -7A 4-271 x V2 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FID0S). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: DI) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month 02%) Once a week 03) 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? 0 Basic Maint.) No educational requirements ❑2) 1 hour a day 03%) More that 3 hours per day Comments: ❑ 1) Less than a 'h hour per day 01%) 'h hour a day 02 %) 1142 hours per day 03) 2'/r3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑ 1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%x) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a..1 to this child. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ O ❑ ❑ ❑ IN Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ • • Enuresis/Encopresis ❑ ❑•❑•❑ ❑ Runaway ❑•❑•❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a . • ly to this child. Inappropriate Sexual Behavior 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: o O O 0 O 0 0 O 0 0 0 O O 0 O 0 O 0 O 0 ❑ ❑ O 0 O 0 O 0 ❑ ❑ O 0 ❑ 0 O 0 O 0 O 0 o O O O O O O 0 0 0 o O 0 O o O O O 0 0 O 0 O O 0 O 0 O O 0 o O (check level of need) E 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2'% ❑ 3 ❑ 3'/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board By: / /47 !LIL Deputy t►`"erk to Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Steitz, Daniel and Natalie 1701 Elder Ave Greeley, CO 80631 It:/SBy:r By: I Gl-Q.t'L A-;AkAD 8 Weld County Addendum to the CW5-7A /p-/- INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, Ja,vE- "Js, O009 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Van Den Elzen, Dawn, Provider ID#44282, 7219 W 20th St Ln, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 07122/ — i97cf 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: (All Ciair Signature AUG G 5 2009 PROVIDER Van Den Elzen, Dawn 7219 W 20th St Ln Greeley, CO 80634 By: .3n0u„ A7 7,217", 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Van Den Elzen, Dawn and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this 25 day of ✓ILNC , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#44282. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CW -7A CSI -/87 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A S -7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? DBasic Maint.) Less than one round trip a week O2) 3-4 round trips a week. ❑3'/z) 7 round trips or more Comments: ❑1) One round trip a week O1%) 2 round trips a week O2%) 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 ❑2) Three times a month O3%) Three times a week or more Comments: ❑1) Once a month ❑1%) Two times month O2%) Once a week O3) 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 ❑1) Less than a''/z hour per day ❑1'/z) %z hour a day ❑2) 1 hour a day O2 Yz) 1'/z-2 hours per day O3) 2'/z-3 hours per day O 3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8 to 10 hours per week ❑2'%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1%) 5 to 7 hours per week ❑2%z) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ l) Face-to-face contact one timeper month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month O2) 4-8 hours per month O3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child. 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 ❑ ❑ ❑ ❑ ❑ ❑ ■ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a . . 1 to this child. Inappropriate Sexual Behavior 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: O ❑ O ❑ O 0 ❑ 0 O ❑ O 0 O 0 O 0 O 0 O 0 (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 2% ❑ 3 ❑ 3'/z 6 Weld County Addendum to the CWS- WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 1 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) A.e 15-21...$19.27/da $586/month + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 1/2 4.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 2 1/2 4.66 Respite Care Total Rate = ($30.25 day/$920 month) 3 $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 31/2 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board geS B Deputy erk to tit, Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature AUG 0 5 2009 PROVIDER Van Den Elzen, Dawn 7219 W 20th St Ln Greeley, CO 80634 BY: Zfin 4, ji71,, 8 Weld County Addendum to the CWS-7A -7A cC2— /cP7 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, `Limp Zb0`1 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Wade, Michael and Jodyne, Provider ID#1554152, 1016 Cottonwood Dr, Windsor, CO 80550, hereinafter called 'Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. x 7. Not to accept money from parents or guardians. N 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see thqhild at any reasonable time. 1 700 -/87f - '11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. 12. 13. 14. To invite the provider to Administrative Reviews for Children in placement. To incorporate provider information in planning for the child. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld ountyjClerlc to the By: Deputy , - k to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature PROVIDER Wade, Michael and Jodyne 1016 Cottonwood Dr Windsor, CO 80550 AUG 0 5 2009 By: 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Wade, Michael and Jodyne and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this 2'5 day of ,\ Un C , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1554152. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the C W5 -7A - 'g' •,4 7A15- but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3'/) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week ❑2'/o 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month 02%) Once a week 03) 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? O Basic Maint.) No educational requirements ❑1) Less than a'h hour per day 01%) 1/2 hour a day ❑2) 1 hour a day 02 %) 1'/r2 hours per day 03) 2%-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week O 3) Constant basis during awake hours ❑3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: ❑ 1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time Der month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3',4 Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..l to this child Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ • Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑• 0 Destructive of Property/Fire Setting ❑ ❑ ❑ 0 ❑ ■ ■ Stealing ❑ ❑ ❑ ❑ ❑ ❑ ■ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ ■ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ • • Enuresis/Encopresis ❑ ❑ ❑ ❑•❑ ❑ Runaway ❑ ❑ ❑ ❑ ❑ ❑ • Sexual Offenses ❑ ❑ ❑ ❑ ❑ ■ ■ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a to this child. Inappropriate Sexual Behavior 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 ❑ 2A ❑ 3 ❑ 3/ 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Wade, Michael and Jodyne 1016 Cottonwood Dr Windsor, CO 80550 By:N D tic,3/44 By: L 714 -V , 8 Weld County Addendum to the CWS-7A U9 —/8)7q Y INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT DOC 1. THIS CONTRACT AND AGREEMENT, made this date, f w ( by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, White, Richard and Melissa, Provider ID#1545830, 3109 W 13th St, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 &e69 - AS -)75/ ' 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County, Clerk to t Deputyi%erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: 41 Chair Signature PROVIDER White, Richard and Melissa 3109 W 13th St Greeley, CO 80634 AUG 0 5 2009 3 cox,-/f7V WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between White, Richard and Melissa and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this / day of Agreement. Except as modified hereby, all terms e Agreement remain unchanged. GENERAL PROVISIONS , 2009, are added to the referenced 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1545830. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A S -7A c2cc %—/P7`1 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FID0S). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3%a) 7 round trips or more Comments: 01) One round trip a week 01%) 2 round trips a week 02 IA) 5 round trips a week ❑3) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? O Basic Maint.) No participation required 02) Three times a month ❑3'/z) Three times a week or more Comments: 01) Once a month 01%) Two times month ❑2%z) Once a week 03) 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 ❑1) Less than a''/z hour per day 01%) %z hour a day 02) 1 hour a day 02 %) 1'/:-2 hours per day 03) 2'/z-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%,) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑ 2) 8 to 10 hours per week 031/2) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week 03) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑ Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ l) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/z) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. 0 0 0 ❑ 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway 0 0 Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a . . 1 to this child. 0 0 0 0 0 0 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 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2'h ❑ 3 ❑ 3'/ 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A•e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A•e 11-14...$18.05/da $549/month A•e 15-21...$19.27/da $586/month + Res • ite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk Deputy 'erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: hair Signature UG 0 5 2009 PROVIDER White, Richard and Melissa 3109W13thSt Greeley, CO 80634 8 Weld County Addendum to the CWS-7A &(e9 -/P77 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7Om/ d between the Board of Weld County Commissioners, sitting as the Board of Social Services,ohalf of the Weld County Department of Human Services, hereinafter called "County Departme nd, Willert, Melody D and Lee, Kimberly, Provider ID#1540372, 219 N 4th St, LaSalle, COA645, hereinafter called "Provider." f� 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until LZ June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 ofc }— /e'7i/ 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to t B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Willed, Melody D and Lee, Kimberly 219 N 4th St LaSalle, CO 80645 By: By: 3 O2OO9- /3'7 y WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Willert, Melody D and Lee, Kimberly and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of Agreement. Except as modified hereby, all terms cif tl Agreement remain unchanged. GENERAL PROVISIONS , 2009, are added to the referenced 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1540372. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FID0S). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. • 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: O 1) One round trip a week ❑1%) 2 round trips a week ❑2Y:) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑ 1) Once a month ❑1'/) Two times month 02%) Once a week 03) 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 01) Less than a %z hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 'A) 11/2-2 hours per day 03) 2%r3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑I) Less than 5 hours per week ❑1%) 5 to 7 hours per week 02) 8 to 10 hours per week 02 'A) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1%) 5 to 7 hours per week 02%) 11 to 15 hours per week 03) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one timelier month with child and no crisis intervention. (i.e. mutual care placements.) ❑l) Face-to-face contact one time per month with child and minimal crisis intervention. 011/2) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑ 1) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 0 ❑ ❑ 0 0 0 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 5 Weld County Addendum to the CWS-7A S -7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a ly to this child. Inappropriate Sexual Behavior 0 0 Disruptive Behavior Delinquent Behavior 0 ❑ Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care ❑ 0 Education Involvement with Child's Family 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 11/2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 3% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) County Basic Maintenance Rate 1 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 1/2 4.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $29.59 2 1/2 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) 3 $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 31/2 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to Deputy irk to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Willert, Melody D and Lee, Kimberly 219 N 4th St LaSalle, CO 80645 By: m\ By: C 8 Weld County Addendum to the CWS-7A cRa79- /P, INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, I / 02009 by and between the Board of Weld County Commissioners, sitting as the B arcjf Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Brilla, Debbie, Provider ID#30451, 2018 20th St Rd, Greeley, CO 80631, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 :oo2- /J'/5 411. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to t By: Deputy r'k 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: WA C 1 Chair Signature AUG 0 5 2009 PROVIDER Brilla, Debbie 2018 20th St Rd Greeley, CO 80631 By: e 3 7a-12 - /P, WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Brilla, Debbie and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this ) day of Agreement. Except as modified hereby, all terms oPthqAgreement remain unchanged. GENERAL PROVISIONS , 2009, are added to the referenced 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#30451. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A • 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week ❑ 2) 3-4 round trips a week. ❑ 3%) 7 round trips or more Comments: 01) One round trip a week 011/2) 2 round trips a week ❑2%) 5 round trips a week 03) 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 02) Three times a month ❑3%) Three times a week or more Comments: 01) Once a month ❑1%) Two times month 02%) Once a week 03) 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 ❑1) Less than a '/1 hour per day 01%) '/ hour a day 02) 1 hour a day 02 %) 1'/-2 hours per day 03) 2%r3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑3/) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 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. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑ 0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a . • ly to this child. 0 0 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions 0 Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ■ ■ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ 0 ❑ ❑ ❑ ❑ • Emancipation ❑ ❑ ❑ ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ • ■ Boundary Issues ❑ ❑ ❑ ❑ ❑ • ■ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ 0 Education ❑ ❑•❑ ❑ • ■ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1% ❑ 2 ❑ 2'h ❑ 3 ❑ 3'/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 A.e 0-10...$16.32/da $496/month A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/montt + Respite Care $.66/da $20/mont $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7P 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 B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Brilla, Debbie 2018 20th St Rd Greeley, CO 80631 By: 8 Weld County Addendum to the CWS-,O4,, ci _,/J27 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, Ur'>L Z i Z ei by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Cordova, Freddie and Linda, Provider ID#1556594, 4017 Harbor Ln, Evans, CO 80620, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 &co 2- /f 7' -11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 -4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. Deputy %erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature PROVIDER Cordova, Freddie and Linda 4017 Harbor Ln Evans, CO 80620 AUG 0 5 2009 3 c9009— /J27'7 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care„ Services and Foster Care Facility Agreement (the "Agreement") between F Cordova, Freddie and Linda and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this ZS"day of 'SU , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1556594. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, /47 I Weld County Addendum to the C S -7A acani-/x'751 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A • 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A S -7A P1. WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? asic Maint.) Less than one round trip a week 01) One round trip a week ❑1Y:) 2 round trips a week 2) 3-4 round trips a week. 02%) 5 round trips a week 03) 6 round trips a week 03%) 7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? O Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month ❑2%x) Once a week g) Two times month ) 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? asic Maint.) No educational requirements 2) 1 hour a day 031/2) More that 3 hours per day Comments: ❑1) Less than a''/3 hour per day 01%) %3 hour a day 02 %) 1%-2 hours per day 03) 2'/:-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hou per week ❑2%x) 11 to 14 hours per week O 3) Constant basis during awake hours ❑3') Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? 12 Basic Maint.) 0-2 hours per week 8 to 10 hours per week 3/) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week 03) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. /) Face-to-face contact one time per month with child and occasional crisis intervention. 2) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. . **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a . • 1 to this child. Aggression/Cruelty to Animals Verbal or Physical Threatening O O 0 0 0 Destructive of Property/Fire Setting Stealing Self -injurious Behavior 0 Substance Abuse 0 Presence of Psychiatric Symptoms/Conditions 0 Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensi of conditions which create the need for services that an • I to this child. 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 0 0 0 Education Involvement with Child's Family \c 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) I Lf 0 m 1 m 11/4 ❑ 2 PE 21/2 ❑ 3 ❑ 3'/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTE, T: WcI4,Coty Clerk to the Board Deputy ' erk to th 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 AUG 0 5 2009 PROVIDER Cordova, Freddie and Linda 4017 Harbor Ln Evans, CO 80620 8 Weld County Addendum to the CWSS_ -7A e/p 7 fT� rO INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 712- D9 by and between the Board of Weld County Commissioners, sitting as the Bo rc of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Fox, Ryan and Emily, Provider ID#1521088, 377 Dogwood Ave, Brighton, CO 80601, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. a I Q?&9- /179 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTE T: Weld ounta42 to the B B 7 Deputy Berk to the Bo Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: PROVIDER WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN ERVICES Chair Signature Fox, Ryan and Emily 377 Dogwood Ave Brighton, CO 80601 AUG 0 5 2009 3 ,;,)on 9_ /x'75 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Fox, Ryan and Emily and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this day of I c H , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1521088. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A S -7A 42LYof- /e% but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week Er) One round trip a week 011/2) 2 round trips a week 02) 3-4 round trips a week. 02%) 5 round trips a week 03) 6 round trips a week 03%) 7 round trips or more Comments: P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month 031/2) Three times a week or more Comments: [V]Y) Once a month ❑1%) Two times month ❑2%z) Once a week 03) 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 ❑2) 1 hour a day 03%) More that 3 hours per day Comments: ❑ 1) Less than a '/z hour per day 01%) % hour a day 02 '/z) 11/2-2 hours per day 03) 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? 0 Basic Maint.) No special involvement needed ❑l) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per'eek ❑2%z) 11 to 14 hours per week C ) Constant basis during awake, hours 03%) Nighttime hours pc ,� Comments: .ny e aR Y1e c cks 1)? &tUti 11 (tn31�u1 y d M ' h, ' 15 lam' s ` GL NO NL> w/ 011. t c'- -il an). \ 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 02) 8 to 10 hours per week ❑3'A 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week 03) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 126(ot needed or provided by another source (i.e 02) 4-8 hours per month Di) Less than 4 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the C W S -7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Aggression/Cruelty to Animals Verbal or Physical Threatening Destructive of Property/Fire Setting ./ 0 Stealing Self -injurious Behavior V Substance Abuse ./ Presence of Psychiatric Symptoms/Conditions ❑ 0 Enuresis/Encopresis Runaway Sexual Offenses V 5 Weld County Addendum to the CWS-7, S-7. BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a . . 1 to this child. Inappropriate Sexual Behavior Disruptive Behavior Delinquent Behavior -"lb elk-- -ea prtprictj tat* rcUrc itM pirbb Depressive -like Behavior i Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) V Emancipation V Eating Problems ./ Boundary Issues V Q lad k- Ole Requires Night Care Education ./ Involvement with Child's Family ./ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ I ❑ 11/2 ❑ 2 ❑ 2% ❑ 3 ❑ 3'/: 6 Weld County Addendum to the C WS= WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Age 0-10...$16.32/day ($496/month) A.e 11-14...$18.05/da $549/month Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) AssessmentlEmergency Rate (30 day max) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk Deputy r erk tb the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 7009 PROVIDER Fox, Ryan and Emily 377 Dogwood Ave Brighton, CO 80601 By: By: 8 Weld County Addendum to the CWS-7A (..cni_/'7; INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT " F.,h. 1. THIS CONTRACT AND AGREEMENT, made this date,4( C' 1::455) t-'"(( & by and betwe4,t4 the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Hendrix, Samuel and Shanaine, Provider ID#1553157, 6606 Tenderfoot Ave, Firestone, CO 80504, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at. any reasonable time. 1 D2009— ,f 7/ 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to th By: 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 SERVICE Bv: Chair SignaturepUO 0 5 2009 PROVIDER Hendrix, Samuel and Shanaine 6606 Tenderfoot Ave Firestone, CO 80504 By: 3 c20O 9 - • WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care„, Services and Foster Care Facility Agreement (the "Agreement") between' ° h. Hendrix, Samuel and Shanaine and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made thi> day ofil,% \1k 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1553157. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 7. t Weld County Addendum to the CWS-7 ..., but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FID0S). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A S -7A 4. • 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? 02 Basic Maint.) Less than one round trip a week 3-4 round trips a week. 3/) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 2) Three times a month 031/4) Three times a week or more Comments: 01) Once a month ❑1/) Two times month 02%) Once a week 03) 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 ❑2) 1 hour a day 03%) More that 3 hours per day Comments: ❑l) Less than a''/3 hour per day ❑1'%) 1/2 hour a day 02 %) 1'/r2 hours per day 03) 27:-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 'RI) 8 to 10 hours per week ❑27:) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 37:) Nighttime hour Comments: c') e ptr 1, U j l....:1%!$1\ cy .C cc aC IR"(c\\ tc)(, `e 1 'tea , -(t U �� Y it i ��/-2)\ w� 1� `�1 Pu tti^��ti"��(�C+�lt fi\ P 5. How much time ks the provider requited to assist the child because of impairments beyond age appropriate needs with eedin bathing, grooming, physical, and/or occupational therapy? Rasic Maint.) 0-2 hours per week .2) 8 to 10 hours per week ❑37:) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) .Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3/) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month 9) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7 WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions t ❑ 44. Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7 BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that ap.1 to this child. Disruptive Behavior Delinquent Behavior Depressive -like Behavior 0 Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation 0 0 C)\0V'CL Y Cl _U (Q 1 (21c l5, t \Je- - Tana.a iA Eating Problems Boundary Issues 0 0 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'/ 6 Weld County Addendum to the CWS-7 WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) /Nile 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Res. ite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7 S-7 IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: hair Signature AUG 0 5 2009 PROVIDER Hendrix, Samuel and Shanaine 6606 Tenderfoot Ave Firestone, CO 80504 8 Weld County Addendum to the CWS-7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT \• -9 p, 0: ,y 1. THIS CONTRACT AND AGREEMENT, made this date, Y 3 l by and between the Board of Weld County Commissioners, sitting as the oard of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Hernandez, Roberto and Margarita, Provider ID#1520297, 912 Elm Ct, Fort Lupton, CO 80621, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTE T: Weld Cto the By: Deputy %erk to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature PROVIDER Hernandez, Roberto and Margarita 912 Elm Ct Fort Lupton, CO 80621 By By: /1"47-1-61514n4s, 2009 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Hernandez, Roberto and Margarita .- n and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this —] day of Agreement. Except as modified hereby, all terms of tf tt e Agreement remain unchanged. GENERAL PROVISIONS , 2009, are added to the referenced 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1520297. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A islet(- /x'79 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week grl %) 2 round trips a week 02%) 5 round trips a week 3) 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 ❑2) Three times a month 03%) Three times a week or more Comments: 01) Once a month 02%) Once a week • 11/2) Two times month a ) 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? O Basic Maint.) No educational requirements Dl) Less than a %z hour per day 011/2) 1/2 hour a day 02) 1 hour a day %z) 1'/z-2 hours per day 03) 2%z-3 hours per day ❑3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed On Less than 5 hours per week 011/2) 5 to 7 hours per week 02) 8 to 10 houeer week 02%) 11 to 14 hours per week Constant basis during awake hours 03%) Nighttime hours omments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 1%) 5 to 7 hours per week 02%) 11 to 15 hours per week ) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. ❑2) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. ❑3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 0) Not needed or provided by another source (i.e. Medicaid) 01) Less than 4 hours per month 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior 1 Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 0 Runaway 0 Sexual Offenses sQ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. ❑ 0 0 0 Disruptive Behavior Delinquent Behavior O Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) O 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 ❑1 ❑ 1% ❑ 2 ❑ 2% 1713 ❑ 3% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) Respite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board ‘,44, Deputy rk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Siam atur eAUG 0 5 rang PROVIDER Hernandez, Roberto and Margarita 912 Elm Ct Fort Lupton, CO 80621 By: By: pit, 8 Weld County Addendum to the CW -7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, a , ,5 - by and between the Board of Weld County Commissioners, sitting as the Board o ocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Holmgren, David and Dawn, Provider ID#1522699, 101 Poudre Bay, Windsor, CO 80550, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 ,cc r-- 1?7y 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. Clerk to the Deputy erk to the Bo By: 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: 1/217 / Chair Signature PROVIDER Holmgren, David and Dawn 101 Poudre Bay Windsor, CO 80550 By: By: AUG 0 5 2009 3 a'Do9- / S77 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Holmgren, David and Dawn and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this , ' day of " `C ` , 2009, are added to the referenced Agreement. Except as modified here yy,, all terms of the A eement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider 1D#1522699. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-74 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A • 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑ Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑ 1) One round trip a week ❑1%) 2 round trips a week O2%) 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 O3%) Three times a week or more Comments: O 1) Once a month 01%) Two times month O2%) Once a week O3) 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 m special education plan? ❑ Basic Maint.) No educational requirements ❑2) 1 hour a day O3%) More that 3 hours per day Comments: ❑ 1) Less than a 'h hour per day 01%) % hour a day O 2 %) 1'h-2 hours per day O3) 2'/:-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ l) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0) Not needed or provided by another source (i.e. Medicaid) 01) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS- WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. 0 0 ❑ ❑ 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 5 Weld County Addendum to the CWS- BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a . • ly to this child. Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ O ❑ ❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ • Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ■ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ • Education ❑ ❑ ❑ ❑ a ■ ■ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ■ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1% ❑ 2 ❑ 2% ❑ 3 ❑ 3/ 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) County Basic Maintenance Rate 1 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 1/2 4.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $29.59 2 1/2 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) 3 $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 3 112 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) 4 TRCCF Drop Down AssessmentlEmergency Rate (30 day max) Effective 7/1/2008 $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Deputy ry` erk to t ti 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 AUG 0 5 2009 PROVIDER Holmgren, David and Dawn 101 Poudre Bay Windsor, CO 80550 8 Weld County Addendum to the CWS-7A aCO2 /d'7 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date 1" lo {f1 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Hunt, Olen J and Nina, Provider 1D#1503154, 224 48th Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 goo9-/e 71 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to t By: Deputy '"rk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature PROVIDER Hunt, Olen J and Nina 224 48th Ave Greeley, CO 80634 By: By: AUG 0 5 2009 3 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Hunt, Olen J and Nina and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this ID day of 2009, are added to the referenced Agreement. Except as modified hereby, all terms o the greement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1503154. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A 0,2609-/897 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month ❑1'/) Two times month 02%) Once a week 03) 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? 0 Basic Maint.) No educational requirements ❑2) 1 hour a day 03%) More that 3 hours per day Comments: ❑ 1) Less than a '/z hour per day 01%) %z hour a day 02 %) 1'/z-2 hours per day 03) 2'/:-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑ 1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week ❑3%z) 21 or more hours per week Comments: ❑ 1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2'/z) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ l) Face-to-face contact one time per month with child and minimal crisis intervention. O 1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ is Delinquent Behavior ❑ ❑ ❑ ❑ ❑ • ■ Depressive -like Behavior ❑ ❑ ❑ ❑ ■ ■ • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ ❑ ❑ Emancipation ❑ O ❑ ❑ ❑ ❑ • Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ • Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ • Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF (check level of need) ❑ 0 ❑ NEED FROM BEHAVIOR ASSESSMENT: ❑ 2 ❑ 2'/ ❑ 3 ❑ 3'/ 1 • 11/2 6 Weld County Addendum to the CWS-7A S -7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) County Basic Maintenance Rate 1 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $29.59 2 1/2 4.66 Respite Care Total Rate = ($30.25 day/$920 month) 3 $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 31/2 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Deputy erk fo 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 Chair Signature PROVIDER Hunt, Olen J and Nina 224 48th Ave Greeley, CO 80634 By: By: i•C\, 0< AUG O5200s Weld County Addendum to the CWS-7A .2ir9—i_P74' • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT /2• -6 r'ar 1. THIS CONTRACT AND AGREEMENT, made this date (JL41i 12-0( by and between the Board of Weld County Commissioners, sitting as the Board of Sociaj Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Jackson, Scott and Andrea, Provider ID#1536689, 425 Hickory Ln, Johnstown, CO 80534, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 crg_ ie7y 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld CLto t �I By: Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Jackson, Scott and Andrea 425 Hickory Ln Johnstown, CO 80534 3 c906 7V WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Cat Services and Foster Care Facility Agreement (the "Agreement") between Jackson, Scott and Andrea and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I Siday of Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. '6 t..-1 , 2009, are added to the referenced GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1536689. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A cC2O r- /4"7 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FID0S). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A S -7A 4.. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? Basic Maint.) Less than one round trip a week ❑1) One round trip a week ❑1%) 2 round trips a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: P 2. How often is'the fo ter c r provide required to participate in child's therapy or counseling sessions? 02%) 5 round trips a week ❑3) 6 round trips a week Basic Maint.) No participation required ❑1) Once a month 01%) Two times month 02) Three times a month 02%) Once a week ❑3) Two times a week ❑3'%) Three times a week or more Comments: vi(CV iV1r,X11l,'r c�,\\ P 3. How much time is the provider require' intervene at h�ouue.and/or at school with the child in conjunction with a regular or special education plan? Basic Maint.) No educational requirements ❑l) Less than a %: hour per day 011/2) '/2 hour a day 02) 1 hour a day 02 '/) 1'/:-2 hours per day 03) 2'/z-3 hours per day 03%) More that 3 hours per day Comments: 11 i (\ c 4flccA o,}t-t- P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ,asic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? Basic Maint.) 0-2 hours per week 2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑l) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 031/2) 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? S0) Not needed or provided by another source (i.e. Medicaid) ❑l) Less than 4 hours per month 2) 4-8 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that ap.ly to this child Aggression/Cruelty to Animals ❑ 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing 0 Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway 0 0 0 0 60( )00)-001 Sexual Offenses 5 Weld County Addendum to the CWS- BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a.' I to this child. Inappropriate Sexual Behavior ��11,, AI ❑ ❑ ❑ ❑ O • Disruptive Behavior �, L� ❑ ❑ ❑ ❑ ❑ U Delinquent Behavior P ❑ ❑ ❑ ❑ ❑ ❑ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑p ❑ ❑ ❑ ❑ t J -Y1.) SGYTt ('1 I Ss k7 4-C %2 e/! • Emancipation a ❑ Eating Problems 111N❑ ❑ ❑ ❑•❑ Boundary Issues a ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ q ❑ ❑ ❑ ❑ ‘t. Li; l ace 3 / 4 (iu& 1 tuz Education `,�, P ❑ ❑ ❑ ❑ ❑ • Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2'h ❑ 3 ❑ 3'h 6 Weld County Addendum to the CWS WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Aqe 0-10...$16.32/day ($496/month) Aqe 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the C WS -7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to th1:oard WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By:✓IL/i / /[' i ' �` :�� t �� By: Deputy Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Jackson, Scott and Andrea 425 Hickory Ln Johnstown, CO 80534 8 Weld County Addendum to the CWS-7A >?nc - /87 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, / ,2c09 by and between the Board of Weld County Commissioners, sitting as the B rd Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Kilgore, Julius and Pamela, Provider ID#1538189, 1740 7th Ave, Greeley, CO 80631, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 ;&to2. - A 7 11•. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. Deputy =rk to t Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: PROVIDER Kilgore, Julius and Pamela 1740 7th Ave Greeley, CO 80631 `._ ) By:Cz-ppc,.2. By: 9 ItZ.4a /�D�r, n 2-- 3 07©69- /d'7' WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Kilgore, Julius and Pamela and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this £'J day of 7 , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1538189. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. Weld County Addendum to the CWS-7A ,70051.—/c9%9 C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑ l) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑ l) Once a month 01%) Two times month O 2%) Once a week 03) 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? O Basic Maint.) No educational requirements 02) 1 hour a day 03%) More that 3 hours per day Comments: ❑1) Less than a'' 'A hour per day 01%) '/z hour a day 02 'A) 11/2-2 hours per day 03) 2'A-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3% Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 ❑ 1 ❑ 1'% ❑ 2 ❑ 2'/: ❑ 3 ❑ 3''/ 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Deputy C erk to th 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 C By: Chair Signature AUG 0 5 2009 PROVIDER Kilgore, Julius and Pamela 1740 7th Ave Greeley, CO 80631 By: By: 2_, I 8 Weld County Addendum to the CWS-7A &on9- i4' 7y E INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT I' 1. THIS CONTRACT AND AGREEMENT, made this date, B6 Ate 0 / by and between the Board of Weld County Commissioners, sitting as the and of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Kniss, Kevin and Kelly, Provider ID#1524303, 1545 71st Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 :p 2-/J'75 11.* To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld CountyjClerJf to the Deputy erk to -the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: AUG 0 5 2009 Chair Signature PROVIDER Kniss, Kevin and Kelly 1545 71st Ave Greeley, CO 80634 By: By: ✓ c._� ✓ 3 &Ci7f- / 7r WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Kniss, Kevin and Kelly and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this 6,1 day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1524303. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A • (90°Y- /e) 7V but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4.• 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑ 1) One round trip a week 01%) 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 ❑2) Three times a month ❑3%) Three times a week or more Comments: ❑ l) Once a month 01%) Two times month O2%) Once a week O3) 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? 0 Basic Maint.) No educational requirements 01) Less than a''/z hour per day 01%) %z hour a day ❑2) 1 hour a day O2 %) 1'/z-2 hours per day O3) 2'/z-3 hours per day O3%2) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8 to 10 hours per week O2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month O2) 4-8 hours per month O3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. 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 0 0 0 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a to this child 0 0 0 ❑ 0 0 Disruptive Behavior 0 Delinquent Behavior Depressive -like Behavior 0 0 0 Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems 0 Boundary Issues 0 Requires Night Care 0 Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1 % ❑ 2 ❑ 2'/ ❑ 3 ❑ 3% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A A • 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 Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: ZA/7 f �� Chair S1gnatur0 0 5 2009 PROVIDER Kniss, Kevin and Kelly 1545 71st Ave Greeley, CO 80634 8 Weld County Addendum to the CWS-7A S -7A ;,?Dc2— /P741 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, -1f (a4p9 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Loschen, Todd and Alicia, Provider ID#1528352, 1747 68th Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 (9a)i_ /F7Y 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to the Board By: Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature PROVIDER Loschen, Todd and Alicia 1747 68th Ave Greeley, CO 80634 AUG 0 5 2009 3 &&'9- /879 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care ?' Services and Foster Care Facility Agreement (the "Agreement") between Loschen, Todd and Alicia and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this .7 day of 1 r , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of e eement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1528352. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 9 1 Weld County Addendum to the CWS-7A 02009- /87S1 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 031/2) 7 round trips or more Comments: 01) One round trip a week ❑1%:) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month ❑3/) Three times a week or more Comments: ❑1) Once a month ❑1%) Two times month ❑2'/) Once a week 03) 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 ❑1) Less than a''/z hour per day ❑1/) %z hour a day 02) 1 hour a day 02 %) 1'/:-2 hours per day 03) 2'/-3 hours per day ❑3%z) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑l) Less than 5 hours per week ❑1'/) 5 to 7 hours per week ❑2) 8 to 10 hours per week 021/2) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 031/2) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 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.) DI) Face-to-face contact one time per month with child and minimal crisis intervention. 011/2) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%z) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a . • 1 to this child. 0 0 0 0 0 0 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 5 Weld County Addendum to the CWS-7 BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 0 0 0 0 0 O Disruptive Behavior O O O 0 O O O Delinquent Behavior O O 0 O O 0 O Depressive -like Behavior 0 0 O O O 0 O Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) O O O 0 0 0 O Emancipation O 0 0 O O O O Eating Problems O O O O O O O Boundary Issues O O O 0 0 Requires Night Care 0 0 0 O 0 0 O Education O O O 0 O 0 0 Involvement with Child's Family 0 0 0 O O O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2% ❑ 3 ❑ 3% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature AUG 0 5 2009 PROVIDER Loschen, Todd and Alicia 1747 68th Ave Greeley, CO 80634 By: By: 8 Weld County Addendum to the CWS-7A 0709-/f `. • INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT i ? p,., j,. -1 the 1. THIS CONTRACT AND AGREEMENT, made this date, Cb1by and between the Board of Weld County Commissioners, sitting as the Bo d o ocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Middleton, Brian and Deborah, Provider ID#1537851, 2418 W. 24th St Rd, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 02O02- /°751 ' 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTE T: Weld ount Clerk to the By: Deputy .► erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: air Sigrfature AUG 0 5 2009 PROVIDER Middleton, Brian and Deborah 2418 W. 24th St Rd Greeley, CO 80634 3 02a°9- a 7 f7 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Middleton, Brian and Deborah and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of Agreement. Except as modified hereby, all terms df thfAgreement remain unchanged. GENERAL PROVISIONS , 2009, are added to the referenced 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1537851. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWV, 7O7 " _ but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3') 7 round trips or more Comments: 01) One round trip a week ❑1%:) 2 round trips a week ❑2%) 5 round trips a week 03) 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 02) Three times a month ❑3%z) Three times a week or more Comments: ❑1) Once a month ❑1%) Two times month 02%) Once a week 03) 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? O Basic Maint.) No educational requirements ❑2) 1 hour a day 03%) More that 3 hours per day Comments: ❑1) Less than a'h hour per day ❑1%)'% hour a day 02 %) 11/4-2 hours per day 03) 2'/2-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%:) 11 to 14 hours per week O 3) Constant basis during awake hours ❑3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond aue appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: 01) 3 to 4 hours per week ❑1%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY MB NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a to this child. 0 0 0 ❑ 0 0 0 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 0 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 0 0 ❑ 0 0 Disruptive Behavior 0 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 0 Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ i ❑ 1 %2 ❑ 2 ❑ 2% ❑ 3 ❑ 31/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Age 0-10...$16.32/day ($496/month) A•e 11-14...$18.05/da $549/month Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the C W S-7/ IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to e_Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Deputy .rk to Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: c By: Chair Signature UG 0 5 2009 PROVIDER Middleton, Brian and Deborah 2418 W. 24th St Rd Greeley, CO 80634 By: By: 8 Weld County Addendum to the CWS-7A cQno9- ,P7l t INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT rrn 1. THIS CONTRACT AND AGREEMENT, made this date, y and betwee the Board of Weld County Commissioners, sitting as the Board of ocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Murrell, Nicholas and Terri, Provider ID#1547183, 812 Scotch Pine Dr, Windsor, CO 80550, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 ' 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld Countylerk to the B B 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 Chair Signature PROVIDER Murrell, Nicholas and Terri 812 Scotch Pine Dr Windsor, CO 80550 By: /l AUG 0 5 2009 BYTa ' \ 3 07609 -/fly WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of FosterCare Services and Foster Care Facility Agreement (the "Agreement") betweeiP , Murrell, Nicholas and Terri and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this n day of _A31\1 , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the 'Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1547183. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4`h of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7& but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A S -7A 4: 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑ 1) One round trip a week ❑ I1/4) 2 round trips a week ❑2'/) 5 round trips a week 03) 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 02) Three times a month ❑3%:) Three times a week or more Comments: ❑l) Once a month ❑1%) Two times month 02%) Once a week 03) 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 m special education plan? ❑ Basic Maint.) No educational requirements DI) Less than a'/z hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 %) 1'h-2 hours per day 03) 2%r3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑l) Less than 5 hours per week 011/2) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'%:) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1%:) 5 to 7 hours per week 02%) 11 to 15 hours per week 03) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one timeper month with child and no crisis intervention. (i.e. mutual care placements.) Dl) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2'/o Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑o) Not needed or provided by another source (i.e. Medicaid) 01) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the C W S- i WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. Aggression/Cruelty to Animals Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse 0 Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 0 0 0 5 Weld County Addendum to the CWS-7 BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a . . 1 to this child Inappropriate Sexual Behavior 0 0 0 0 ❑ 0 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 ❑1 ❑ 1'/z ❑ 2 ❑ 2% ❑ 3 ❑ 3% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) County Basic Maintenance Rate 1 Aqe 0-10...$16.32/day ($496/month) Aqe 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) 2 $29.59 21/2 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) 3 $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 31/2 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Effective 7/1/2008 $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS- IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to - : card WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES B Deputy Clerk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: By: Chair Signature AUG 0 5 2009 PROVIDER Murrell, Nicholas and Tern 812 Scotch Pine Dr Windsor, CO 80550 8 Weld County Addendum to the CWS-7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date 6' �(� (v )-o0 1 by and between the Board of Weld County Commissioners, sitting as the oard f Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Parker, Brian and Beryldell, Provider ID#1538709, 230 N 53rd Ave PL, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 • 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to By: Deputy erk o the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature PROVIDER Parker, Brian and Beryldell 230 N 53rd Ave PL Greeley, CO 80634 By: By: 3 .2o09- /PP` WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Parker, Brian and Beryldell and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this (p' day of 1 , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the greement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1538709. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. Weld County Addendum to the CWS-7A Cr1- /cf71 C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: 01) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 ❑2) Three times a month 03%) Three times a week or more Comments: 01) Once a month 01%) Two times month ❑2'%:) 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 of special education plan? ❑ Basic Maint.) No educational requirements ❑1) Less than a''/3 hour per day 01%) 1/2 hour a day ❑2) 1 hour a day 02 %) 1'/z-2 hours per day 03) 2'/-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond ate appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the C W S-' WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child. 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions 0 Enuresis/Encopresis Runaway Sexual Offenses 0 5 Weld County Addendum to the CWS- BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..l to this child 0 0 0 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) 0 Emancipation Eating Problems 0 Boundary Issues 0 0 Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'/ ❑ 2 ❑ 2% ❑ 3 ❑ 3'/z 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County C1er to the Board Deputy C 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: C/ Chair Signature AUG 0 5 2009 PROVIDER Parker, Brian and Beryldell 230 N 53rd Ave PL Greeley, CO 80634 By: By: 8 Weld County Addendum to the CWS-7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT , -6 P„ /2: I 1 1. THIS CONTRACT AND AGREEMENT, made this date - eon by and between the Board of Weld County Commissioners, sitting as the BoSocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Redding, Christopher and Sonja, Provider ID#1524128, 2305 42nd Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. I :2702 -if 7Y 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES rk to the Bo By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature PROVIDER Redding, Christopher and Sonja 2305 42nd Ave Greeley, CO 80634 AUG 0 5 2009 3 77Cn%-/d' J/ WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Cie Services and Foster Care Facility Agreement (the "Agreement") between An Redding, Christopher and Sonja and the J // 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 o th greement remain unchanged. GENERAL PROVISIONS County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1524128. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing maybe denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A _ -JOp J*' but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FID0S). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3'A) 7 round trips or more Comments: ❑1) One round trip a week ❑1%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month ❑1%:) Two times month ❑2'/) Once a week 03) 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 01) Less than a'' /z hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 02 %) 11/2-2 hours per day 03) 2'/r3 hours per day ❑3%:) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week ❑1%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week 0 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week ❑1/) 5 to 7 hours per week ❑2'%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a.ply to this child. 0 0 0 ❑ 0 0 0 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 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that ap.l to this child. Inappropriate Sexual Behavior 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 ❑1 ❑ 1% ❑ 2 ❑ 2% ❑ 3 ❑ 3% 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) Aqe 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7A S -7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES B AUG 0 5 2009 PROVIDER Redding, Christopher and Sonja 2305 42nd Ave Greeley, CO 80634 8 Weld County Addendum to the CWS-7A 2x9-i?7f' f INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date n I by and between the Board of Weld County Commissioners, sitting as the B rd cial Services, on behalf of the Weld County Department of Human Services, hereinafter c lied "County Department" and, Reyna, Ali and Jessica, Provider ID#1502220, 3304 Syrah St, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 01a12- /cr74 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEaT: Weld C,punlyjCler; tot By: Deputy C rk to Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature AUG 0 5 2009 PROVIDER Reyna, Ali and Jessica 3304 Syrah St Greeley, CO 80634 r By� 3 c9005-1— /F7Y WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Reyna, Ali and Jessica and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of Agreement. Except as modified hereby, all terms o#tlWAgreement remain unchanged. GENERAL PROVISIONS , 2009, are added to the referenced 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1502220. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 1 Weld County Addendum to the CWS-7A S -7A o2a19— /cf 75/ but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. ❑3%) 7 round trips or more Comments: �, ❑ ) One round trip a week 01%) 2 round trips a week %) 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 Comments: 01) Once a month 01%) Two times month O2%) Once a week O3) 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? CI Basic Maint.) No educational requirements DI) Less than a %I hour per day 01%) %z hour a thy ❑2) 1 hour a day O2 '/:) 1'/r2 hours per day O3) 2%:-3 hours per day ❑31A) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of lime and/or activities and/or crisis management? i ]-Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week O2%) 11 to 14 hours per week O 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? DBasic Maint.) 0-2 hours per week 01) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑'2) 8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week O3%) 21 or more hours per week Comments: A 1. How often is CPA/County case management required? (Does not include therapy) Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑ l%) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O3) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'A) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? to) Not needed or provided by another source (i.e. Medicaid) 01) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a . . 1 to this child. 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 4 0 Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. Disruptive Behavior Delinquent Behavior CI Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) a Emancipation Eating Problems Boundary Issues r Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/= ❑ 2 ❑ 2% ❑ 3 ❑ 31/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County CI , .-'tktB9 rd IFf> . J B Deputy C'rk to the'Botr e . Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair SignatureAUG 0 5 2009 PROVIDER Reyna, Ali and Jessica 3304 Syrah St Greeley, CO 80634 By: By: i 8 Weld County Addendum to the CWS-7A X7 /F757 9 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, (� I �((D by and between the Board of Weld County Commissioners, sitting as the Boar of ocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Ripka, Gary and Jennifer, Provider ID#1538429, 2113 74th Ave, Greeley, CO 80634, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 L -2(e9 - /e7y f1. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to t B Deputy erk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: 'rector WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signa ure AUU U 5 20( PROVIDER Ripka, Gary and Jennifer 2113 74th Ave Greeley, CO 80634 3 far -i5)77 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Ripka, Gary and Jennifer and the Weld County Department of Human Services for the period from July 1, 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 t Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1538429. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A 024709-/S27 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4.. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? Basic Maint.) Less than one round trip a week O2) 3-4 round trips a week. O3%) 7 round trips or more Comments: ❑1) One round trip a week ❑1%:) 2 round trips a week O2%) 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 O3%) Three times a week or more Comments: ❑1) Once a month ❑1%i Two times month ❑2%) Once a week O3) 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 ❑1) Less than a %2 hour per day 01%) '/2 hour a day ❑2) 1 hour a day O2 %a) 1'/z-2 hours per day ❑3) 2%r3 hours per day O3%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8 to 10 hours per week ❑2%%) 11 to 14 hours per week O 3) Constant basis during awake hours O3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond a¢e appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? O Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week O3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑ Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑11) Face-to-face contact one time per month with child and occasional crisis intervention. O2) Face-to-face contact two times per month with child and occasional crisis intervention. O2%) Face-to-face contact three times per month with child and occasional crisis intervention. O 3) Face-to-face contact weekly with child and occasional crisis intervention. O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 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 5 Weld County Addendum to the CWS-7A S -7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..l to this child. Inappropriate Sexual Behavior 0 0 0 ❑ 0 0 0 Disruptive Behavior Delinquent Behavior O Depressive -like Behavior O Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) 0 O O Emancipation 0 0 O Eating Problems Boundary Issues 0 0 0 0 O O Requires Night Care O Education 0 0 Involvement with Child's Family O 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1% ❑ 2 ❑ 2'h ❑ 3 ❑ 3'/z 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down AssessmentlEmerge ncy Rate (30 day max) Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7P 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: Mid Deputy CI-rk to th 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 hair Signature AUG 0 5 2009 PROVIDER Ripka, Gary and Jennifer 2113 74th Ave Greeley, CO 80634 By. 8 Weld County Addendum to the CWS-7A INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT'? fi,, j 1 q 1. THIS CONTRACT AND AGREEMENT, made this date 1'UA, � by and between the Board of Weld County Commissioners, sitting as the Board of ocial Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Ritter, Thomas and Deborah, Provider ID#1554009, 10136-Dearfield-StFirestone, Co so -iv -Inner, hereinafter called "Provider." \C161 J0nsyW\o 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 X11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTE, T: Weld County, Clerk to the Bo Deputy ''rk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Bv: Chair ignature AUG 0 5 2009 PROVIDER Ritter, Thomas and Deborah 10136 Deal field St 10 151 bV0Y1411 vQ. Firestone, CO 80520- y Q� By: By: C?l 3 „?Doi /7y WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Ritter, Thomas and Deborah / f' and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this 1 day of , , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of th�ement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1554009. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 4 1 Weld County Addendum to the CWS-7A oar 9- /279 but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? Aflasic Maint.) Less than one round trip a week J2) 3-4 round trips a week. ❑3%:) 7 round trips or more Comments: 01) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: ❑1) Once a month 01%) Two times month 02%) Once a week 03) 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? 42 Basic Maint.) No educational requirements ) 1 hour a day 03%) More that 3 hours per day Comments: ❑l) Less than a %z hour per day 01%) '/z hour a day 02 %) 1'/2-2 hours per day 03) 2%-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? , Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) Basic Maint.) Face-to-face contact one timeper month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? X) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month 02) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A 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. Aggression/Cruelty to Animals ❑ ❑ 0 0 0 Verbal or Physical Threatening P Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 0 0 0 14. Runaway Sexual Offenses 5 Weld County Addendum to the CWS- BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ Disruptive Behavior 0 ❑ ❑ ❑ ❑• ■ Delinquent Behavior 14 ❑ ❑ ❑ ❑ ■ ■ Depressive -like Behavior W ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) gi ❑ ❑ ❑ ❑ ❑ ❑ Emancipation 0 ❑ ❑ 0 ❑ •❑ Eating Problems ❑ ❑ ❑ ❑ ❑ ■ Boundary Issues Yi ❑ ❑ ❑ ■ ■ ■ Requires Night Care ❑ ❑ ❑ ❑ ❑ ■ Education 7 ❑ ❑ ❑ ❑ ❑ ■ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ■ CHILD'S OVERALL (check level of need) LEVEL DS} OF NEED FROM BEHAVIOR ASSESSMENT: �/ ❑ I ❑ PA ❑ 2 ❑ 2'A ❑ 3 ❑ 3% 6 Weld County Addendum to the CWS• WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) AssessmentlEmerge ncy Rate (30 day max) Effective 7/1/2008 Aqe 0-10...$16.32/day ($496/month) Aqe 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7A IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to Deputy C -rk to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature uc 0 5 2009 PROVIDER Ritter, Thomas and Deborah �rdst 10 )51 1;ev6.7\4111(tR? Firestone, CO 80520 By: By: 8 Weld County Addendum to the CWS-7A 02009- i4 7 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 6'/ So/0 9 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Rogers, Jeffrey and Tami, Provider ID#1550689, 5221 Bowersox Parkway, Firestone, CO 80504, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 02(509 - %P79' 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk Deputy a =rk to the Board J F :� Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature PROVIDER Rogers, Jeffrey and Tami 5221 Bowersox Parkway Firestone, CO 80504 AUG 0 5 2009 3 (9009-/f7 / WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") bet -Weer%,% Rogers, Jeffrey and Tami '6 and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this Jv day of <J Unr` , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1550689. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 46 of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, 2 1 Weld County Addendum to the CWS-7A but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3'h) 7 round trips or more Comments: 01) One round trip a week 01%) 2 round trips a week ❑2'/o 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: 0 1) Once a month 01%) Two times month 2'/z) 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 of special education plan? ❑ Basic Maint.) No educational requirements 1) Less than a'' /z hour per day 011/2) 1/2 hour a day ❑2) 1 hour a day 2 /) 1'/z-2 hours per day 03) 2'/z-3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? tgBasic Maint.) No special involvement needed ❑1) Less than 5 hours per week ❑1%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%z) 11 to 14 hours per week O 3) Constant basis during awake hours ❑3%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? Basic Maint.) 0-2 hours per week 2) 8 to 10 hours per week 03%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2'%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2Yz) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month 2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS- WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Crue4t ttr Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. ❑ 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting cst Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 0 5 Weld County Addendum to the CWS- BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. Disruptive Behavior Delinquent Behavior Depressive -like Behavior nc Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues O Requires Night Care Education oL Involvement with Child's Family Genes a liz2 e Nbo �`�"�` CJ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 i1 ❑ 11/2 ❑ 2 ❑ 2th ❑ 3 ❑ 3%2 6 Weld County Addendum to the CWS- WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maintenance Rate 1 1 1/2 2 2 1/2 3 3 112 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Res. ite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 4.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) Effective 7/1/2008 $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS, IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk By:/7C/14 Deputy Clerk to the Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature PROVIDER Rogers, Jeffrey and Tami 5221 Bowersox Parkway Firestone, CO 80504 AUG O 5 2009 8 Weld County Addendum to the CWS-7A O1OO% - /P7 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, T3, `(O17OO by and between the Board of Weld County Commissioners, sitting as the Boardrdf Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Shindle, Danny and Andrea, Provider ID#1550177, 1606 Fairacres Rd., Greeley, CO 80631, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 &a32- /327/ 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Welfl C�ountyjCler, to By: Deputy a`erk to the B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature PROVIDER Shindle, Danny and Andrea 1606 Fairacres Rd. Greeley, CO 80631 By. 77?. By L,!``, CCt JLjke \ AUG 0 5 2009 3 �ODf-/di4( WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Shindle, Danny and Andrea and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this fO day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of thetgreement remain unchanged. GENERAL PROVISIONS 1. County and Provider 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 Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1550177. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. C. Placement service reimbursement shall be paid from the date of placement up to, Weld County Addendum to the CWS-7A r9cr9- /o°74/ but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 4.. 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: 01) One round trip a week 01%) 2 round trips a week ❑2%) 5 round trips a week 03) 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 02) Three times a month ❑3%' Three times a week or more Comments: ❑1) Once a month 01%) Two times month 02%) Once a week 03) 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? 0 Basic Maint.) No educational requirements 02) 1 hour a day 03%) More that 3 hours per day Comments: ❑1) Less than a''/z hour per day 01%) 1/2 hour a day 02 Y) 1'h-2 hours per day 03) 2'/-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond aee appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? 0 Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑ Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) O 1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑ 1) Less than 4 hours per month 02) 4-8 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a . . 1 to this child. 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 ❑ ❑•❑ • 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑•❑ ❑• 0 Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑• • Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑•❑ ❑ • Emancipation ❑ ❑ ❑ ❑ ❑ ❑ • Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ I Boundary Issues ❑ ❑ ❑ ❑ ❑ ■ ■ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ 0 ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'A ❑ 2 ❑ 2'/z ❑ 3 ❑ 3%z 6 Weld County Addendum to the CWS-7P WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maintenance Rate 4 TRCCF Drop Down Assessment/Emergency Rate (30 day max) A•e 0-10...$16.32/da $496/month Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 ♦$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk ard WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES B Mid Deputy irk to th Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: By: Chair Signature AUG 0 5 2009 PROVIDER Shindle, Danny and Andrea 1606 Fairacres Rd. Greeley, CO 80631 8 Weld County Addendum to the CWS-7A 0261% /9 7 INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT 1. THIS CONTRACT AND AGREEMENT, made this date, 7 1 I 1O01 by and between the Board of Weld County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County Department of Human Services, hereinafter called "County Department" and, Walker, Kurt and Jennifer, Provider ID#1546248, 519 Trout Creek Ct, Windsor, CO 80550- 3194, hereinafter called "Provider." 2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto and relating to the services herein described. 3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home. Such certification standards shall be maintained during the term hereof. The provider has read and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by the Colorado Department of Human Services. 4. The County Department may, but shall not be obligated to, purchase foster care services. The County Department or any duly authorized agent may request such services to be provided to any child at any time within the limits of the certificate and without prior notice. At such time or as soon as possible after the acceptance of a child for services, the County Department and the Provider shall verify foster care placement of each child in writing on the required form, which shall become an addendum to this contract, subject to all the terms and conditions hereof. The Provider agrees: 1. To furnish foster care services to eligible children at the established rate based on type of facility and individual child rates negotiated between the county and the provider. 2. To safely provide the 24 -hour physical care and supervision of each child until removed or until the agreement is renewed. 3. To accept children only with the approval of the certifying/licensing agency. 4. To cooperate fully with the County Department or its representatives, and participate in the development of the Family Service Plans for children in placement, including visits with their parents, siblings, and relatives, or transition to another foster care facility. 5. To maintain approved standards of care as set by the State Department of Human Services. 6. To keep confidential the information shared about the child and his/her family. 7. Not to accept money from parents or guardians. 8. Not to make any independent agreement with parents or guardians. 9. Not to release the child to anyone without prior authorization from the Department. 10. To allow representatives of the County Department to visit the foster home and to see the child at any reasonable time. 1 0100%-/172/ " 11. To give the County Department two weeks notice, except in an emergency, to remove a child for placement elsewhere and to work with the County Department as requested in preparing the child for the next placement. 12. To provide transportation to the child to enable the utilization of professional services when necessary. The amount of transportation to be provided will be agreed upon at placement and may be changed upon mutual agreement of the provider and the County Department, as recorded in the Family Services Plan. 13. To report promptly to the Department: a. Any unplanned absence of the child from provider's care. b. Any major illness of the child. c. Any serious injury to the child. d. Any significant change in the child's sleeping arrangement. e. Any contemplated change of address or change of household members. f. Any conflict the child may have with law enforcement, school officials, or other persons in the authority. g. Any emergency. h. Any pertinent discussion with parents or guardians about the child or supervising agency. i. Any information received regarding a change of address of the parents or guardians. 14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin, or handicap. 15. To attend core certification training prior to the placement of any child. 16. To attend on -going training as required by State Department regulations. 17. To attend Administrative Reviews for children in placement. 18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized Group Facilities. 19. Not to enter into any subordinate subcontract hereunder. 20. To keep such records as are necessary for audit purposes by state and federal personnel. The records shall document the type of care and the term during which care is provided for each child. In addition, medical, educational, and progress summary records shall be maintained for each child in accordance with Volume 7 requirements. 21. To maintain medical, dental and educational records for each child/youth and supply updated information to the County Department. Department agrees: 1. To share all available information about the child, including relevant social, medical and educational history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific characteristics of the child, with the provider before placement and to share additional information when obtained. 2. To inform the provider of expectations regarding the care of the child, such as meeting medical needs, handling special psychological needs, and separation/loss issues. 3. To arrange for a medical examination of the child before placement or within 14 days after placement and give a copy of the completed form to the out -of -home provider. 2 4. To give the provider a written record of the child's admission to the home at the time of placement. 5. To give the provider a written procedure or authorization for obtaining medical care for the child. 6. To involve the provider in service planning for the child as part of the overall treatment team. 7. To give the provider a copy of the Family Services Plan for the child at the time of placement or as soon as it is completed following placement. 8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice may be waived by mutual consent to allow immediate removal of said child for placement elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in which a provider's inability to provide services threatens the health, safety or welfare of children. 9. To pay the provider at the rates established by the State Department of Human Services or as negotiated between the provider and the county. The rate of payment per month shall be based on the type of facility and individual rates. Payment shall be by warrant drawn by the duly authorized county officer. 10. To provide or arrange through statewide contracted training a minimum of twelve hours of core certification training for family foster homes. The county department is responsible for providing information on county specific procedures. 11. To invite the provider to Administrative Reviews for Children in placement. 12. To incorporate provider information in planning for the child. 13. To assure that the service described herein has been accomplished and a record made thereof on a case by case basis. 14. To provide notice of hearings. Additional Agreement regarding a Particular Child: Please refer to the Weld County Addendum and the child specific Needs Based Care Addendum to this agreement. ATTEST: Weld County Clerk to t 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 Signatur PROVIDER Walker, Kurt and Jennifer 519 Trout Creek Ct Windsor, CO 80550-3194 AUG 0 5 2009 By: By: 4s4-, R \>30. -- 3 a'oor- if 7V WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Walker, Kurt and Jennifer and the Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of 3 uA , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1546248. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall: A. Be submitted in a format approved by the County. If submitted in an unapproved format or inadequate documentation is provided, the County reserves the right to deny payment. B. Be submitted by the 4th of each month following the month of service. If the reimbursement request is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. Weld County Addendum to the CWS-7A 07a9 -/F 1� C. Placement service reimbursement shall be paid from the date of placement up to, but not including the day of discharge. D. Transportation reimbursement shall be for visitation purposes only. Any other special request for transportation reimbursement shall require prior approval by the Service Utilization Unit Manager or the Department Administrator. E. Clothing allowance reimbursement shall be approved and reimbursed as indicated on the clothing allowance form accessed through the Foster Parents Database On- line System (FIDOS). 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. Provider shall be notified by Department staff of the date and time of the utilization review. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Care Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 2 Weld County Addendum to the CWS-7A 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 Provider. All documentation of these examinations will be placed in the foster child's placement binder. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 6. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 7. To maintain, access and review information weekly on the Foster Parents Internet Database On-line System (FIDOS). 8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook which can be accessed through FIDOS. 9. To maintain/update information in the foster child's binder. The binder will be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Care Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child. 11. Comply with all County and State certification requirements as set forth in the State Department rules, Staff Manual Volume VII and the Weld County Department of Human Services Policy and Procedure manual. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more Comments: ❑ 1) One round trip a week 01%) 2 round trips a week 021/2) 5 round trips a week 03) 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 02) Three times a month 03%) Three times a week or more Comments: 01) Once a month 01%) Two times month ❑2%) Once a week 03) 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 01) Less than a'' /z hour per day 01%) 1/2 hour a day ❑2) 1 hour a day 02 %) 11/2-2 hours per day 03) 2%r3 hours per day 03%) More that 3 hours per day Comments: P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours Comments: P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding, bathing, grooming, physical, and/or occupational therapy? 0 Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑3%) 21 or more hours per week Comments: ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week 03) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 01) Less than 4 hours per month ❑2) 4-8 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7A WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child. 0 0 0 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 5 Weld County Addendum to the CWS-7A BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. 0 0 0 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems 0 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 ❑ I% ❑ 2 ❑ 2% ❑ 3 ❑ 31/2 6 Weld County Addendum to the CWS-7A WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Assessment/Emergency Rate (30 day max) Effective 7/1/2008 Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) 7 Weld County Addendum to the CWS-7, IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Bv: Deputy '' erk to th Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Si a ature AUG 0 5 2009 PROVIDER Walker, Kurt and Jennifer 519 Trout Creek Ct Windsor, CO 80550-3194 By: By: 449- 8 Weld County Addendum to the CWS-7A a�f— iefi Hello