HomeMy WebLinkAbout20091870.tiffMEMORANDUM
DATE: July 30, 2009
WIN.TO: William F. Garcia, Chair, Weld County Board of
O Commissioners ; f i/i,
COLORADO
FROM: Judy A. Griego, Director, Human Serices)epartmefit '
RE: Weld County Addendum to Purchase Child Placement Agency
Services between the Weld County Department of Human Services
and Various Contractors to be Placed on the Consent Agenda
Enclosed for Board approval arc Weld County Addendums to Purchase Child Placement Agency Services
between the Weld County Department of Human Services and Contractors listed below. Please place on the
Consent Agenda.
Below are the major provisions of the attached Agreements:
No.
Facility Name/Term
Type of Facility/Location
Daily Rate
1
Adoption Alliance
July 1, 2009 — June 30, 2010
Group Home/Foster Home
Denver, Colorado
$ I6.32-$40.11
2
Adoption Options
July 1, 2009 — June 30, 2010
Group Home/Foster Home
Aurora, Colorado
$16.32-$40.11
3
Bethany Christian Services
July I , 2009 — Junc 30, 2010
Group Home/Foster Home
Colorado Springs, Colorado
$1 6.32-$40.11
4
Gateway Youth and Family
July 1, 2009 — June 30, 2010
Group Home/Foster Home
Grand Junction, Colorado
$16.32-$40.11
5
Hope Family Services
July 1, 2009 — June 30, 2010
Group Home/Foster Home
Greeley, Colorado
$16.32-$40.11
6
Kids Crossing
July 1, 2009 — June 30, 2010
Group Home/Foster Home
Colorado Springs, Colorado
$16.32-$40.11
7
Youth Ventures of Colorado
July I, 2009 — June 30, 2010
Group Home/Foster Homc
Colorado Springs. Colorado
$16.32-$40.11
If you have any questions, give me a call at extension 6510.
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2009-1870
460t4;
111k
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 22, 2009
The Weld County Addendum to the Agreement to Purchase
Out -Of -Home Placement Services contracts for Child
Placement Agency Services.
Attached please find the Weld County Addendum to the Agreement to Purchase Out -Of -Home
Placement Service Contracts for Child Placement Agency Services for following providers:
Weld County
Child Placement Agency Providers
2009-2010
1 Adoption Alliance
2 Adoption Options
3 Bethany Christian Services
4 Gateway Youth and Family
5 Hope Family Services
6 Kids Crossing
7 Youth Ventures of Colorado
2121 S. Oneda St, Suite
71259 420
13900 E Harvard Ave,
45078 Suite 200
45514
95568
42942
4820 Rusina Rd, Suite C
740 Gunnison Ave
1610 29th Ave Place #100
79752 1440 E Fountain Blvd
1554849 4785 Granby Cir
Denver, CO 80224
Aurora, CO 80014
Colorado Springs, CO
80907-8127
Grand Junction, CO 81501
Greeley, CO 80634
Colorado Springs, CO
80910-3502
Colorado Springs, CO
80919
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.
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Adoption Alliance and Weld County Department
of Human Services for the period from
July 1, 2009 through June 30, 2010.
The following provisions, made this / day of
Agreement. Except as modified hereby, all terms Agreement remain unchanged.
, 2009, are added to the referenced
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#71259. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person -to -person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non -regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. Contractor
shall be notified by Department staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
Weld County SS -23A Adden um9_/n,7
Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 8 weeks after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS -23A Addendum
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII -ATTACHMENTS:
3
Weld County SS -23A Addendum
IDENTIFYING INFORMATION
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
CHILD'S NAME
WORKER COMPLETING ASSESSMENT
STATE ID#
AGENCY NAME
PROVIDER NAME
SEX TRAILS CASE ID 1DOB
M F I I
HH# '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.
❑ 3%) 7 round trips or more
❑ 1) 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
DI) 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 of
special education plan?
0 Basic Maint.) No educational requirements
02) 1 hour a day
❑3%x) More that 3 hours per day
❑1) Less than a''/ hour per day 01%) 1/2 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?
❑ 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 ❑3%) Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feedin
bathing, grooming, physical, and/or occupational therapy?
0 Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week ❑1%) 5 to 7 hours per week
02) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
O11/2) Face-to-face contact one time per month with child and occasional crisis intervention.
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)
02) 4-8 hours per month
4
❑1) Less than 4 hours per month
03) 9-12 hours per month
Weld County SS -23A Addend,
..L,1.11 a..v Vl\ l a vno
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
O
Runaway
Sexual Offenses
5
Weld County SS -23A Addendu
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensit of conditions which create the need for services that a..l to this child
0 0 0 ❑ 0 0 0
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
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'h
6 Weld County SS -23A Addends
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
County
Basic
Maint.
4
RTC Drop
Down
Assess/
Emergency
Level
Rate
(30 Day
Max)
Admin. Overhead Rate:
$6.91 day/$210.00 month
Age 0-10...$16.32
($496)
Age 11-14...$18.05
($549)
Age 15-21...$19.27
($586)
+ $.66 Respite Care
($20)
$19.73
+$.66 Respite Care
($20.39 day/$620 mo)
$23.01
+$.66 Respite Care
($23.67 day/$720 mo)
$26.30
+$.66 Respite Care
($26.96 day/$820 mo)
$29.59
+$.66 Respite Care
($30.25 day/$920 mo)
$32.88
+$.66 Respite Care
($33.54day/$1020 mo)
$36.16
+$.66 Respite Care
($36.82 day/$1,120 mo)
$39.45
4.66 Respite Care
($40.11 day/$1220 mo)
$30.25 day/$920 mo
(Includes Respite)
Basic Maint $4.93 day/$150mo
No crisis intervention, Minimal CPA
involvement, one face-to-face visit
with child per month.
Level 1 $8.22 day/$250 mo
Minimal crisis intervention as needed,
one face-to-face visit per month with
child,
2-3 contacts per month
Level 1 1/2$9.86 day/$300 mo
Level 2 $11.51 day/$350 mo
Occasional crisis intervention as needed,
two face-to-face visits with child,
2-3 contacts per month
Level 2 1/2 $13.15 day/$400 mo
Level 3 $14.79 day/$450 mo
Ongoing crisis intervention as needed,
weekly face-to-face visits with child,
and intensive coordination of
multiple services.
Level 3 1/2 $16.44 day/$500 mo
Level 4 $18.08 day/$550 mo
Ongoing crisis intervention as needed,
which includes high level of case
management and CPA involvement with
child and provider and 2-3 face-to-face
contacts rer week minimum.
As of 7/01/08
$13.15 day/$400 mo
Level 0 $0
Therapy not needed or provided
by
another source, i.e. mental health.
Level 1 $4.93/$150 mo
Regularly scheduled therapy,
up to 4 hours/month.
Level 2 $9.86/$300 mo
Weekly scheduled therapy,
5-8 hours a month with 4 hours of
group therapy.
Level 3 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 4 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 0...$0
(None)
Level 1 ...$2.99
Level 2..$4.47
Level 3..$6.02
Level 4....Neg.
7
Weld County SS -23A Addendu
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:
Deput /' lerk to the
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
CONTRACTOR AUG 0 5 2009
Adoption Alliance
2121 S. Oneda St, Suite 420
Denver, CO 80224
By:
8
Weld County SS -23A Addendum
&a99-/J'%Ti
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Adoption Options and Weld County Department
of Human Services for the period from
July 1, 2009 through June 30, 2010.
The following provisions, made this 1' Ilk day of , 2009, are added to the referenced
Agreement. Except as modified hereby, all terns the A eement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#45078. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person -to -person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non -regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. Contractor
shall be notified by Department staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1
Weld County SS -23A Addendui,
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 8 weeks after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2
Weld County SS -23A Addendum
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII - ATTACHMENTS:
3
Weld County SS -23A Addendum
IDENTIFYING INFORMATION
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
CHILD'S NAME
WORKER COMPLETING ASSESSMENT
STATE ID#
SEX trRAILS CASE ID
M F
DOB
HH# 'DATE OF ASSESSMENT
AGENCY NAME
PROVIDER NAME
PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
❑ Basic Maint.) Less than one round trip a week
02) 3-4 round trips a week,
❑ 3'/) 7 round trips or more
❑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
02) Three times a month
031/2) Three times a week or more
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 ❑1'/s) '/z hour a day
02) 1 hour a day 02 %z) 11/4-2 hours per day 03) 2'/z-3 hours per day
03%) More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week ❑1/) 5 to 7 hours per week
❑2) 8 to 10 hours per week 021/2) 11 to 14 hours per week
❑ 3) Constant basis during awake hours ❑31) 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 ❑1%) 5 to 7 hours per week
02) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑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%z) 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?
00) Not needed or provided by another source (i.e. Medicaid)
02) 4-8 hours per month
4
❑1) Less than 4 hours per month
❑3) 9-12 hours per month
Weld County SS -23A Addends
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.
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 SS -23A Addends
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.
❑ ❑
Disruptive Behavior
O
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 SS -23A Addends
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
County
Basic
Maint.
4
RTC Drop
Down
Assess/
Emergency
Level
Rate
(30 Day
Max)
Admin. Overhead Rate:
$6.91 day/$210.00 month
Age 0-10...$16.32
($496)
Age 11-14...$18.05
($549)
Age 15-21...$19.27
($586)
+ $.66 Respite Care
($20)
$19.73
+$.66 Respite Care
($20.39 day/$620 ma)
$23.01
+$.66 Respite Care
($23.67 day/$720 mo)
$26.30
+$.66 Respite Care
($26.96 day/$820 mo)
$29.59
+$.66 Respite Care
($30.25 day/$920 mo)
$32.88
+$.66 Respite Care
($33.54day/$1020 mo)
$36.16
4.66 Respite Care
($36.82 day/$1,120 mo)
$39.45
+$.66 Respite Care
($40.11 day/$1220 mo)
$30.25 day/$920 mo
(Includes Respite)
Basic Maint $4.93 day/$150mo
No crisis intervention, Minimal CPA
involvement, one face-to-face visit
with child per month.
Level 1 $8.22 day/$250 mo
Minimal crisis intervention as needed,
one face-to-face visit per month with
child,
2-3 contacts per month
Level 1 1/2 $9.86 day/$300 mo
Level 2 $11.51 day/$350 mo
Occasional crisis intervention as needed,
two face-to-face visits with child,
2-3 contacts per month
Level 2 1/2 $13.15 day/$400 mo
Level 3 $14.79 day/$450 mo
Ongoing crisis intervention as needed,
weekly face-to-face visits with child,
and intensive coordination of
multi • le services.
Level 3 1/2 .... ..$16.44 day/$500 mo
Level 4 $18.08 day/$550 mo
Ongoing crisis intervention as needed,
which includes high level of case
management and CPA involvement with
child and provider and 2-3 face-to-face
contacts .er week minimum.
$13.15 day/$400 mo
Level 0 $0
Therapy not needed or provided
by
another source, i.e. mental health.
Level 1 $4.93/$150 mo
Regularly scheduled therapy,
up to 4 hours/month.
Level 2 $9.86/$300 mo
Weekly scheduled therapy,
5-8 hours a month with 4 hours of
group therapy.
Level 3 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthl
Level 4 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 0...$0
(None)
Level 1 ...$2.99
Level 2..$4.47
Level 3..$6.02
Level 4....Neg.
As of 7/01/08
7
Weld County SS -23A Addend
, IN, WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board
B
Deputy ' lerk lo the Boa
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
CoArct t7.0 Director J
CAL
lw�
7
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature AUG 0 5 2009
CONTRACTOR
Adoption Options
13900 E Harvard Ave, Suite 200
Aurora, CO 80014
By: Hool
8
Weld County SS -23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Bethany Christian Services and Weld County
Department of Human Services for the period from
July 1, 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 greement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#45514. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person -to -person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non -regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. Contractor
shall be notified by Department staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
Weld County SS -23A Addendum
d1CD'1—/27<
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 8 weeks after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2
Weld County SS -23A Addendum
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII - ATTACHMENTS:
3
Weld County SS -23A Addendum
IDENTIFYING INFORMATION
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
CHILD'S NAME
WORKER COMPLETING ASSESSMENT
AGENCY NAME
STATE ID#
SEX !TRAILS CASE ID IDOB
M F I
HH# !DATE OF ASSESSMENT
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:
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
O2) 3-4 round trips a week.
O3%) 7 round trips or more
Du 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?
O Basic Maint.) No participation required
❑2) Three times a month
O 'A) Three times a week or more
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%) 'A hour a day
O2) 1 hour a day O2 %) 1'/z:-2 hours per day O3) 2'/,-3 hours per day
O3%) More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ 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 ❑3'%z) Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing, grooming, physical, and/or occupational therapy?
O Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2/) 11 to 15 hours per week O3) 16 to 20 per week
O3%) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'/z) 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)
O2) 4-8 hours per month
❑1) Less than 4 hours per month
❑3) 9-12 hours per month
Weld County SS -23A Addendum
4
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 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 SS -23A Addendum
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
0
Education
Involvement with Child's
Family
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 1111 ❑ 11/4 ❑ 2 ❑ 2'h ❑ 3 ❑ 3'h
6
Weld County SS -23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
County
Basic
Maint.
4
RTC Drop
Down
Assess/
Emergency
Level
Rate
(30 Day
Max)
Admin. Overhead Rate:
As of 7/01/08
Age 0-10...$16.32
($496)
Age 11-14...$18.05
($549)
Age 15-21...$19.27
($586)
+ $.66 Respite Care
($20)
$19.73
+$.66 Respite Care
($20.39 day/$620 mo)
$23.01
+$.66 Respite Care
($23.67 day/$720 mo)
$26.30
+$.66 Respite Care
$29.59
+$.66 Respite Care
($30.25 day/$920 mo)
$32.88
+$.66 Respite Care
($33.54day/$1020 mo)
$36.16
+$.66 Respite Care
($36.82 day/$1,120 mo)
$39.45
+$.66 Respite Care
($40.11 day/$1220 mo)
$30.25 day/$920 mo
(Includes Respite)
Basic Maint $4.93 day/$150mo
No crisis intervention, Minimal CPA
involvement, one face-to-face visit
with child per month.
Level 1 $8.22 day/$250 mo
Minimal crisis intervention as needed,
one face-to-face visit per month with
child,
2-3 contacts per month
Level 1 1/2 $9.86 day/$300 mo
Level 2 $11.51 day/$350 mo
Occasional crisis intervention as needed,
two face-to-face visits with child,
2-3 contacts per month
Level 2 1/2 $13.15 day/$400 mo
Level 3 $14.79 day/$450 mo
Ongoing crisis intervention as needed,
weekly face-to-face visits with child,
and intensive coordination of
multiple services.
Level 3 1/2 $16.44 day/$500 mo
Level 4 $18.08 day/$550 mo
Ongoing crisis intervention as needed,
which includes high level of case
management and CPA involvement with
child and provider and 2-3 face-to-face
contacts •er week minimum.
$13.15 day/$400 mo
Level 0 $0
Therapy not needed or provided
by
another source, i.e. mental health.
Level 1 $4.93/$150 mo
Regularly scheduled therapy,
up to 4 hours/month.
Level 2 $9.86/$300 mo
Weekly scheduled therapy,
5-8 hours a month with 4 hours of
group therapy.
Level 3 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 4.........$14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 0...$0
(None)
Level 1 ...$2.99
Level 2..$4.47
Level 3..$6.02
Level 4....Neg.
$6.91 day/$210.00 month
7
Weld County SS -23A Addenda
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
By: /Z,
Deputy'' lerk to the Boar
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: ( 4
Chair Signature
AUG 0 5 2009
CONTRACTOR
Bethany Christian Services
4820 Rusina Rd, Suite C
Colorado Springs, CO 80907-8127
Byvy 4
8
Weld County SS -23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Gateway Youth and Family and Weld County
Department of Human Services for the period from
July 1, 2009 through June 30, 2010.
The following provisions, made this / day of � 2009, are added to the referenced
Agreement. Except as modified hereby, all terms t Agreement remain unchanged.
3N
designated as Attaehment B, shall be used to determine levels of care for each child
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, h +> N a B __mss __._ . , , off
determined. The specific rate of payment will be paid for each level of service,-as.4H
for children
placed within the CPA identified as Provider ID#95568. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person -to -person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non -regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. Contractor
shall be notified by Department staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
/.
1
Weld County SS -23A Addendun
? ' —/)746
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 8 weeks after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS -23A Addendum
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII — ATTACHMENTS:
3
Weld County SS -23A Addendum
IDENTIFYING INFORMATION _
CHILD'S NAME
WORKER COMPLETING ASSESSMENT
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
STATE ID#
HHis
SEX TRAILS CASE ID
M F
DOB
DATE OF ASSESSMENT
AGENCY NAME
PROVIDER NAME
PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
['Basic Maint.) Less than one round trip a week
❑2) 3-4 round trips a week.
031/2) 7 round trips or more
❑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
❑1) Once a month 011/2) 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%) '/z hour a day
❑2) 1 hour a day 02 %) 1'/:-2 hours per day ❑3) 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 ❑1) Less than 5 hours per week ❑1%x) 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 feedin
bathing, grooming, physical, and/or occupational therapy?
❑ Basic Maint.) 0-2 hours per week ❑ 1) 3 to 4 hours per week ❑ 1%) 5 to 7 hours per week
❑2) 8 to 10 hours per week 021/2) 11 to 15 hours per week ❑3) 16 to 20 per week
03%) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
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)
02) 4-8 hours per month
4
❑1) Less than 4 hours per month
03) 9-12 hours per month
Weld County SS -23A Addendu
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
0
Destructive of
Property/Fire Setting
Stealing
Self -injurious Behavior
Substance Abuse
Presence of Psychiatric
Symptoms/Conditions
Enuresis/Encopresis
0
0
0
0
0
Runaway
0
Sexual Offenses
5
Weld County SS -23A Addendu
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
0 0
Disruptive Behavior
Delinquent Behavior
Depressive -like Behavior
0
0
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 ❑ I''/ ❑ 2 ❑ 2'h ❑ 3 ❑ 3%
6
Weld County SS -23A Addends
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
County
Basic
Maint.
4
RTC Drop
Down
Assess/
Emergency
Level
Rate
(30 Day
Max)
Admin. Overhead Rate:
Age 0-10...$16.32
($496)
Age 11-14...$18.05
($549)
Age 15-21...$19.27
($586)
+ $.66 Respite Care
($20)
$19.73
+$.66 Respite Care
($20.39 day/$620 mo)
$23.01
+$.66 Respite Care
($23.67 day/$720 mo)
$26.30
+$.66 Respite Care
($26.96 day/$820 mo)
$29.59
+$.66 Respite Care
($30.25 day/$920 mo)
$32.88
+$.66 Respite Care
($33.54day/$1020 mo)
$36.16
+$.66 Respite Care
($36.82 day/$1,120 mo)
$39.45
+$.66 Respite Care
($40.11 day/$1220 mo)
$30.25 day/$920 mo
(Includes Respite)
Basic Maint $4.93 day/$150mo
No crisis intervention, Minimal CPA
involvement, one face-to-face visit
with child per month.
Level 1 $8.22 day/$250 mo
Minimal crisis intervention as needed,
one face-to-face visit per month with
child,
2-3 contacts per month
Level 1 1/2.........$9.86 day/$300 mo
Level 2 $11.51 day/$350 mo
Occasional crisis intervention as needed,
two face-to-face visits with child,
2-3 contacts per month
Level 2 1/2.........$13.15 day/$400 mo
Level 3 $14.79 day/$450 mo
Ongoing crisis intervention as needed,
weekly face-to-face visits with child,
and intensive coordination of
multiple services.
Level 3 1/2 $16.44 day/$500 mo
Level 4 $18.08 day/$550 mo
Ongoing crisis intervention as needed,
which includes high level of case
management and CPA involvement with
child and provider and 2-3 face-to-face
contacts .er week minimum.
As of 7/01/08
$13.15 day/$400 mo
Level 0 $0
Therapy not needed or provided
by
another source, i.e. mental health.
Level 1 $4.93/$150 mo
Regularly scheduled therapy,
up to 4 hours/month.
Level 2 $9.86/$300 mo
Weekly scheduled therapy,
5-8 hours a month with 4 hours of
group therapy.
Level 3 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 4 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 0...$0
(None)
Level 1 ...$2.99
Level 2..$4.47
Level 3..56.02
Level 4....Neg.
$6.91 day/$210.00 month
7
Weld County SS -23A Addend'
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Bpard
By:
Deputy fE erk to the Boar
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
CONTRACTOR
Gateway Youth and Family
740 Gunnison Ave
Grand Junction, CO 81501
8
Weld County SS -23A Addendum
L3200 9 _AP x
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Hope Family Services and Weld County
Department of Human Services for the period from
July 1, 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.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#42942. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person -to -person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non -regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. Contractor
shall be notified by Department staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
Weld County SS -23A Addendum
' 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 8 weeks after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS -23A Addendum
' 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII - ATTACHMENTS:
3 Weld County SS -23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME
WORKER COMPLETING ASSESSMENT
STATE ID#
ISEX TRAILS CASE ID
M F I
DOB
HH# DATE OF ASSESSMENT
AGENCY NAME
PROVIDER NAME
PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
['Basic Maint.) Less than one round trip a week
02) 3-4 round trips a week.
❑3%2) 7 round trips or more
❑1) One round trip a week ❑1'/) 2 round trips a week
❑2'/2) 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
031/2) Three times a week or more
❑1) Once a month 011/2) Two times month
❑2%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 of
special education plan?
❑ Basic Maint.) No educational requirements ❑1) Less than a '/2 hour per day 01%) '/2 hour a day
02) 1 hour a day 02 'A) 1'/2-2 hours per day 03) 2'/2-3 hours per day
03%) More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑ 3) Constant basis during awake hours 03%) Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with 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
02) 8 to 10 hours per week D21/2) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%2) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑ Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention.
01%) Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention.
02%) Face-to-face contact three times per month with child and occasional crisis intervention.
03) Face-to-face contact weekly with child and occasional crisis intervention.
03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0) Not needed or provided by another source (i.e. Medicaid)
02) 4-8 hours per month
4
❑1) Less than 4 hours per month
❑3) 9-12 hours per month
Weld County SS -23A Addend,
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 SS -23A Addend,
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensit 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:
0
0
❑ ❑ ❑
❑ 0 ❑
(check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 31/2
6
Weld County SS -23A Addends
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
gr
x+u t ugyy�
%'t`h
County
Basic
Maint.
}
:-
"�Y:� xkk�p} 4h'4 : t a•T
xiT'f
Age 0-10...$16.32
($496)
Age 11-14...$18.05
($549)
Age 15-21...$19.27
($586)
+ $.66 Respite Care
($20)
—6
•
-:
°.
,�,y 1}} 4�'3„ 4 t �'Q„5' M.Pt�4+ i
a S" ),
1. '.�.:°^xt. .., aE hh.
Basic Maint $4.93 day/$150mo
No crisis intervention, Minimal CPA
involvement, one face-to-face visit
with child per month
"
Level 0 $0
Therapy not needed or provided
by
another source, i.e. mental health.
.�
Level 0...$0
l (None)
1
$19.73
+$.66 Respite Care
($20.39 day/$620 mo)
-,.
sha
Level 1 $8.22 day/$250 mo
Minimal crisis intervention as needed,
one face-to-face visit per month with
child,
2-3 contacts per month
Level 1 $4.93/$150 mo
Regularly th
scheduled therapy,
up to 4 hours/month.
Level 1 ...$2.99
..
1 1/2
$23.01
+$.66 Respite Care
($23.67 day/$720 mo)
Level 1 1/2.........$9.86 day/$300 mo
-------- ------------- —
----_-----
2
$26.30
+$.66 Respite Care
($26.96 day/$820 mo)
Level 2 $11.51 day/$350 mo
Occasional crisis intervention as needed,
two face-to-face visits with child,
2-3 contacts per month
Level 2 $9.86/5300 mo
Weekly scheduled therapy,
5-8 hours a month with 4 hours of
group therapy.
x x
€'°
`' Level 2..$4.47
2 1/2
$29.59
+$.66 Respite Care
($30.25 day/$920 mo)
Level 2 1/2$13.15 day/$400 mo
"'f^
^,1
t"
3
;a•
$32.88
+$.66 Respite Care
($33.54day/$1020 ma)
Level 3 $14.79 day/$450 mo
Ongoing crisis intervention as needed,
weekly face-to-face visits with child,
and intensive coordination of
multiple services.
y
='
Level 3 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include,
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 3..$6.02
31/2
$36.16
+$.66 Respite Care
($36.82 day/$1,120 mo)
Level 3 1/2 $16.44 day/$500 mo
--_------
4
RTC Drop
Down
Assess/"
Emergency
Level
Rate
(30 Day
Max)
•
°
iy
$39.45
+$.66 Respite Care
day/$1220 mo)
$30.25 day/$920 mo
(Includes Respite)
•'
;'
Level 4 $18.08 day/$550 mo
Ongoing crisis intervention as needed,
which includes high level of case
management and CPA involvement with
9
child and provider and 2-3 face-to-face
contacts •er week minimum.
$13.15 day/$400 mo
.
,r'
`
°
a4
Level 4 $14.79/5450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1person, i.e. family therap
y,
for 9-12 hours/monthly.
^ s
Level 4....Neg.
--"'---'
Admin. Overhead Rate:
$6.91 day/$210.00 month
As of 7/01/08
7
Weld County SS -23A Addends
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
LAtiaA,
Deputy ' lerk to the Boar
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
CONTRACTOR
Hope Family Services
1610 29th Ave Place #100
Greeley, CO 80634
By:
AUG 0 5 2009
8
Weld County SS -23A Addendu
�7/— /x'7O
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Kids Crossing and Weld County Department of
Human Services for the period from
July 1, 2009 through June 30, 2010.
The following provisions, made this / day of , 2009, are added to the referenced
Agreement. Except as modified hereby, all terms e Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#79752. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person -to -person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non -regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. Contractor
shall be notified by Department staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
Weld County SS -23A Addendum
DX09-/P7O
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 8 weeks after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS -23A Addendum
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII - ATTACHMENTS:
3
Weld County SS -23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME
WORKER COMPLETING ASSESSMENT
STATE ID#
SEX RAILS CASE ID
M F
DOB
HHP 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
02) 3-4 round trips a week.
03%) 7 round trips or more
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
❑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
❑2) 1 hour a day
❑3%i More that 3 hours per day
❑1) Less than a'''A hour per day 01%) 1/2 hour a day
02 Y) 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
❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑ 3) Constant basis during awake hours ❑3%) Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing, grooming, physical, and/or occupational therapy?
❑ Basic Maint.) 0-2 hours per week
02) 8 to 10 hours per week
03%) 21 or more hours per week
❑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)
02) 4-8 hours per month
4
❑1) Less than 4 hours per month
03) 9-12 hours per month
Weld County SS -23A Addendum
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
0
Destructive of
Property/Fire Setting
Stealing
Self -injurious Behavior
Substance Abuse
Presence of Psychiatric
Symptoms/Conditions
Enuresis/Encopresis
0
0
Runaway
Sexual Offenses
5
Weld County SS -23A Addendum
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
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
0
0
0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O
O
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O
O
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2'/ ❑ 3 ❑ 31/2
6
Weld County SS -23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
County
Basic
Maint.
1
1 1/2
2
3
3 1/2
4
RTC Drop
Down
Assess/
Emergency
Level
Rate
(30 Day
Max)
Admin. Overhead Rate:
As of 7/01/08
Age 0-10...$16.32
($496)
Age 11-14...$18.05
($549)
Age 15-21...$19.27
($586)
+ $.66 Respite Care
($20)
$19.73
+$.66 Respite Care
($20.39 day/$620 mo)
$23.01
+$.66 Respite Care
($23.67 day/$720 mo)
$26.30
+$.66 Respite Care
($26.96 day/$820 mo)
$29.59
+$.66 Respite Care
($30.25 day/$920 mo)
$32.88
+$.66 Respite Care
($33.54day/$1020 mo)
$36.16
+$.66 Respite Care
($36.82 day/$1,120 mo)
$39.45
+$.66 Respite Care
($40.11 day/$1220 mo)
$30.25 day/$920 mo
(Includes Respite)
Basic Maint $4.93 day/$150mo
No crisis intervention, Minimal CPA
involvement, one face-to-face visit
with child per month.
Level 1 $8.22 day/$250 mo
Minimal crisis intervention as needed,
one face-to-face visit per month with
child,
2-3 contacts per month
Level 1 1/2 $9.86 day/$300 mo
Level 2 ................$11.51 day/$350 mo
Occasional crisis intervention as needed,
two face-to-face visits with child,
2-3 contacts per month
Level 2 1/2.........$13.15 day/$400 mo
Level 3 $14.79 day/$450 mo
Ongoing crisis intervention as needed,
weekly face-to-face visits with child,
and intensive coordination of
multiple services.
Level 3 1/2 $16.44 day/$500 mo
Level 4 $18.08 day/$550 mo
Ongoing crisis intervention as needed,
which includes high level of case
management and CPA involvement with
child and provider and 2-3 face-to-face
contacts .er week minimum.
$13.15 day/$400 mo
Level 0 $0
Therapy not needed or provided
by
another source, i.e. mental health.
Level 1 $4.93/$150 mo
Regularly scheduled therapy,
up to 4 hours/month.
Level 2 $9.86/$300 mo
Weekly scheduled therapy,
5-8 hours a month with 4 hours of
group therapy.
Level 3 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 4 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 0...$0
(None)
Level 1 ...$2.99
Level 2..$4.47
Level 3..$6.02
Level 4....Neg.
$6.91 day/$210.00 month
7
Weld County SS -23A Addendurt
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board
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
Chair Signature
CONTRACTOR
Kids Crossing
1440 E Fountain Blvd
Colorado Springs, CO 80910-3502
AUG 0 5 2009
8
Weld County SS -23A Addendum
Oc%-- /CP7e--)
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Youth Ventures of Colorado and Weld County
Department of Human Services for the period from
July 1, 2009 through June 30, 2010.
The following provisions, made this day of
Agreement. Except as modified hereby, all terms
, 2009, are added to the referenced
Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#1554849. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished by the Contractor under this contract for
facilities that provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person -to -person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non -regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. Contractor
shall be notified by Department staff of the date and time of the utilization review.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
Weld County SS -23A Addendum
.&2co9-/87Z
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 8 weeks after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS -23A Addendum
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII - ATTACHMENTS:
3
Weld County SS -23A Addendum
IDENTIFYING INFORMATION
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
CHILD'S NAME
WORKER COMPLETING ASSESSMENT
STATE ID#
SEX !TRAILS CASE ID 1DOB
M F I
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
02) 3-4 round trips a week.
❑3'/z) 7 round trips or more
❑l) One round trip a week ❑19:) 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?
O Basic Maint.) No participation required
02) Three times a month
03%) Three times a week or more
❑l) 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 1/2 hour per day ❑1/) %z hour a day
02) 1 hour a day 02 %:) 1'/r2 hours per day 03) 2%-3 hours per day
❑3%) More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.) No special involvement needed ❑l) 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
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?
O Basic Maint.) 0-2 hours per week ❑l) 3 to 4 hours per week ❑1%) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%:) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑l) Face-to-face contact one time per month with child and minimal crisis intervention.
❑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)
02) 4-8 hours per month
❑I) Less than 4 hours per month
03) 9-12 hours per month
Weld County SS -23A Addendu
4
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.1 to this child.
0 0 0 ❑ ❑
Verbal or Physical
Threatening
0
Destructive of
Property/Fire Setting
0
Stealing
Self -injurious Behavior
Substance Abuse
Presence of Psychiatric
Symptoms/Conditions
0
0
Enuresis/Encopresis
O
0
0
Runaway
Sexual Offenses
O
5
Weld County SS -23A Addendum
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
0 0
O 0
O ❑
O 0
0 0
O 0
O 0
O 0
O 0
O 0
O 0
0
0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'/a ❑ 2 ❑ 2'h ❑ 3 ❑ 3/
6
Weld County SS -23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
County
Basic
Maint.
1
1 1/2
2
2 1/2
3
4
RTC Drop
Down
Assess/
Emergency
Level
Rate
(30 Day
Max)
Age 0-10...$16.32
($496)
Age 11-14...$18.05
($549)
Age 15-21...$19.27
($586)
+ $.66 Respite Care
($20)
$19.73
+$.66 Respite Care
($20.39 day/$620 mo)
$23.01
4.66 Respite Care
($23.67 day/$720 mo)
$26.30
4.66 Respite Care
($26.96 day/$820 mo)
$29.59
+$.66 Respite Care
($30.25 day/$920 mo)
$32.88
+$.66 Respite Care
($33.54day/$1020 mo)
$36.16
+$.66 Respite Care
($36.82 day/$1,120 mo)
$39.45
+$.66 Respite Care
$30.25 day/$920 mo
(Includes Respite)
Admin. Overhead Rate:
Basic Maint $4.93 day/$150mo
No crisis intervention, Minimal CPA
involvement, one face-to-face visit
with child per month.
Level 1 $8.22 day/$250 mo
Minimal crisis intervention as needed,
one face-to-face visit per month with
child,
2-3 contacts per month
Level 1 1/2 $9.86 day/$300 mo
Level 2 $11.51 day/$350 mo
Occasional crisis intervention as needed,
two face-to-face visits with child,
2-3 contacts per month
Level 2 1/2.........$13.15 day/$400 mo
Level 3 $14.79 day/$450 mo
Ongoing crisis intervention as needed,
weekly face-to-face visits with child,
and intensive coordination of
multiple services.
Level 3 1/2.........$16.44 day/$500 mo
Level 4 $18.08 day/$550 mo
Ongoing crisis intervention as needed,
which includes high level of case
management and CPA involvement with
child and provider and 2-3 face-to-face
contacts •er week minimum.
As of 7/01/08
$13.15 day/$400 mo
Level 0 $0
Therapy not needed or provided
by
another source, i.e. mental health.
Level 1 $4.93/$150 mo
Regularly scheduled therapy,
up to 4 hours/month.
Level 2 $9.86/$300 mo
Weekly scheduled therapy,
5-8 hours a month with 4 hours of
group therapy.
Level 3 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 4 $14.79/$450 mo
Regularly scheduled weekly
multiple sessions, can include
more
than 1 person, i.e. family therapy,
for 9-12 hours/monthly.
Level 0...$0
(None)
Level 1 ...$2.99
Level 2..$4.47
Level 3..$6.02
Level 4....Neg.
$6.91 day/$210.00 month
7
Weld County SS -23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board
B
Deputy ' 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: tie
Chair Signature
AUG 0 5 2009
CONTRACTOR
Youth Ventures of Colorado
4785 Granby Cir
Colorado Springs, CO 80919
By:
8
Weld County SS -23A Addendum
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