HomeMy WebLinkAbout20092042.tiffMEMORANDUM
N
DATE: August 3, 2009
WIIDC
TO: William F. Garcia, Chair, Boar f oun Co isstoners
FROM: Judy A. Griego, Director, H an See i D rtm t
COLORADO RE:
Addendum to the Individual Provider Contract for Purpose of
Foster Care Services and Foster Care Facility Agreement
between the Weld County Department of Human Services
and Various Providers for Consent Agenda
Request Board approval of an Addendum to the Individual Provider Contract for Purpose of
Foster Care Services and Foster Care Facility Agreement between the Department and Various
Provider. These Contracts were presented at the Boards April 27, 2009, Work Session. Please
place on Consent Agenda.
The major provisions of these Agreements are as follows:
No.
Facility Name/
Term
Type of Facility/
Location
Daily Rate
1
Carter, Jeremy and Susan
April 2, 2009 — June 30, 2009
Foster Home
Greeley, Colorado
$16.32 - $40.11
2
Mauk, James and Harriett
April 6, 2009 - June 30, 2009
Foster Home
Johnstown, Colorado
$16.32 - $40.11
3
McLaughlin, Cynthia
April 10, 2009 — June 30, 2009
Foster Home
Firestone, Colorado
$16.32 - $40.11
If you have questions, please give me a call at extension 6510.
iii((6SY'
trgito log
651,4(01
2009-2042
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Jeremy and Susan Carter
and the
Weld County Department of Human Services
for the period from April 2, 2009 through June 30, 2009.
The following provisions, made this l"1day of , 2009, are added to the referenced
Agreement. Except as modified hereby, all terms of he 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#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 be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing 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
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. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
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 Home 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.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. 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.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME
STATE IDIt
.SEX F [TRAILS CASE ID [DOB
WORKER COMPLETING ASSESSMENT
HEM IRATE OF ASSESSMENT
AGENCY NAME
PROVIDER NAME
PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week
O2) 3-4 round trips a week.
O3%) 7 round trips or more
❑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
❑3'%z) Three times a week or more
❑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
❑ 1) Less than a %z hour per day 01%) 'h hour a day
O2 %:) 1'/r2 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?
O Basic Maint.) No special involvement needed
❑2) 8 to 10 hours per week
O 3) Constant basis during awake hours
01) Less than 5 hours per week
❑2%) 11 to 14 hours per week
❑3'/) Nighttime hours
❑ 1%) 5 to 7 hours per week
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
❑1) 3 to 4 hours per week ❑1%x) 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.
❑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)
O2) 4-8 hours per month
❑1) Less than 4 hours per month
O3) 9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
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
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
(Exhibit B)
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
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:
0 0 0 0
O 0
O 0
O ❑
O 0
O 0
O 0
O 0
O 0
O 0
0
(check level of need) O 0 ❑ 1 ❑ 2 ❑ 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
Maint.
1
1 1/2
2
2 1/2
3
3 112
4
TRCCF Drop Down
Assessment 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
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 CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
By:
Weld County Clerk to the Board
Deputy t'• rk tb the Board
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
WELD COUNTY BOARD OF
HUMAN SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF HUMAN
SERVICES
By: it�lx-f at jail
Pro—i'em Chyjir Sign urelakr
Douglas Rademache
8/10/2009
PROVIDER:
Jeremy & Susan Carter
3332 W. 35th St.
Greeley, Colorado 80634
By: CAi
(Signature)
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
James and Harriett Mauk
and the
Weld County Department of Human Services
for the period from April 6, 2009 through June 30, 2009.
The following provisions, made this pill day of , 2009, are added to the referenced
Agreement. Except as modified hereby, all terms o 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#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 be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
t
Weld County Addendum to the CWS-7A
•
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. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
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 Home 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.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child _
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
' 6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. 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.
8. tin/access information on the Foster Parents Internet Database On-line System
s indicated in the Foster Parent Handbook.
9. To- intain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
IDENTIFYING INFORMATION
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
CHILD'S NAME
WORKER COMPLETING ASSESSMENT
STATE IDH
AGENCY NAME
PROVIDER NAME
SEX [TRAILS CASE ID IDOB
M F I
HEM 'DATE OF ASSESSMENT
PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week
02) 3-4 round trips a week.
03%) 7 round trips or more
❑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
03%) Three times a week or more
❑1) Once a month ❑1'/i) Two times month
021/2) 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 '/, hour per day ❑1'/) %I hour a day
02) 1 hour a day 02 '4) 1'/r2 hours per day 03) 2%r3 hours per day
❑3%) More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week ❑1''/) 5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2''/) 11 to 14 hours per week
❑ 3) Constant basis during awake hours 03%) Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing, grooming, physical, and/or occupational therapy?
❑ Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
01%) Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention.
02%) Face-to-face contact three times per month with child and occasional crisis intervention.
❑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)
02) 4-8 hours per month
❑1) Less than 4 hours per month
03) 9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
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
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
(Exhibit B)
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
0
Delinquent Behavior
Depressive -like Behavior
Medical Needs
(If condition is rated "severe", please complete
the Medically fragile NBC)
0
0
Emancipation
Eating Problems
Boundary Issues
Requires Night Care
0
Education
0
Involvement with Child's Family
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
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
Maint.
1
1 1/2
2
2 1/2
3
3 112
4
TRCCF Drop Down
Assessment Rate
(30 day max)
A•e 11-14...$18.05/da $549/month
As 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)
$23.01
+$.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 CWS-'
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
Deputy Clerk to the Board
Weld County
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
WELD COUNTY BOARD OF
HUMAN SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF HUMAN
SERVICES
By:c mgAu
Pro—Tem air Si nature
Douglas Rademac er
8/10/2009
PROVIDER:
James & Harriett Mauk
3620 Dilley Circle
Johnstown, CO 80534
By: ,x
ilZ1
(Signature)
8
Weld County Addendum to the CWS-7A
ao«—cYC y
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Cynthia McLaughlin
and the
Weld County Department of Human Services
for the period from April 10, 2009 through June 30, 2009.
The following provisions, made this 10th day of April, 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#1556217. 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 be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing 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
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. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
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 Home 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.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. 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.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3
Weld County Addendum to the CWS-7A
IDENTIFYING INFORMATION
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
CHILD'S NAME
WORKER COMPLETING ASSESSMENT
STATE ID#
SEX (TRAILS CASE ID IDOB
M F I
HH# IDATE OF ASSESSMENT
AGENCY NAME
PROVIDER NAME
PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week
O 2) 3-4 round trips a week.
031/2) 7 round trips or more
❑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
03%) Three times a week or more
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 or
special education plan?
❑ Basic Maint.) No educational requirements ❑1) Less than a %z hour per day 01%) %x hour a day
02) 1 hour a day 02 '%) 11/2-2 hours per day 03) 2%r3 hours per day
03%) More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑ 3) Constant basis during awake hours 031/2) Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin
bathing, grooming, physical, and/or occupational therapy?
❑ Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%) Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention.
❑ 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)
02) 4-8 hours per month
❑1) Less than 4 hours per month
❑3) 9-12 hours per month
4 weld County Addendum to the CWS-7
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
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
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
(Exhibit B)
Inappropriate Sexual Behavior
Please rate the behavior/intensity of conditions which create the need for services that a . • I to this child.
❑ ❑ ❑ 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
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 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
Maint.
1
1 1/2
2
2 1/2
3
3 1/2
4
TRCCF Drop Down
Assessment Rate
(30 day max)
Ate 11-14...$18.05/da $549/month
Ate 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
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
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-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
Weld County C}er-k'to th
By:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Deputy O trk to the Board
WELD COUNTY BOARD OF
HUMAN SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF HUMAN
SERVICES
By:
Pro- enC air Sig .cure
Douglas Rademac er
8/10/2009
PROVIDER:
Cynthia McLaughlin
10578 Barron Circle
Firestone, Colorado 80504
0
By: rietiiuc✓ �. /�7, (tuc{�.
(Signature)
8 Weld County Addendum to the CWS-7A
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