HomeMy WebLinkAbout20092234.tiffMEMORANDUM
DATE: August 18, 2009
TO: William F. Garcia, Chair, Board of Co my Corn 'ssion rs
•
FROM: Judy A. Griego, Director, Huma a ce a men
COLORADO RE:
Weld County Addendum to Individurovider Contract for
Purposes of Foster Care Services an oster Care Facility
Agreement between the Weld County Department of Human
Services and Various Providers To Be Placed on Consent
Agenda
Enclosed for Board Approval is the Weld County Addendum to Individual Provider
Contract for Purposes of Foster Care Services and Foster Care Facility Agreement
between the Department and Various Providers. These Addendums were presented at the
Board's August 17, 2009, Work Session.
The major provisions of these Agreements are as follows:
No.
Provider/Term
Type of Facility/ Location
Daily Rates
1
Andrews, Mark and Susan
July 1, 2009 — June 30, 2010
Foster Home
Eaton, Colorado
$16.32 - $40.11
2
Paulsen, Larry and Helen
June 16, 2009 - June 30, 2010
Foster Home
Greeley, Colorado
$16.32 - $40.11
3
Schmidt, Donald and Constance
June 12, 2009 — June 30, 2009
Foster Home
Greeley, Colorado
$16.32 - $40.11
4
Schmidt, Donald and Constance
July 1, 2009 — June 30, 2010
Foster Home
Greeley, Colorado
$16.32 - $40.11
5
Warner, Amy and David
July 9, 2009 — June 30, 2010
Foster Home
Evans, Colorado
$16.32 - $40.11
If you have any questions, give me a call at extension 6510.
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2009-2234
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WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
MARK & SUSAN ANDREWS
and the
Weld County Department of Human Services
for the period from July 1, 2009 through June 30, 2010.
The following provisions, made this ilay of 2009, are added to the referenced
Agreement. Except as modified hereby, all terms f the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre -adoptive
placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1559384. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
C. Placement service reimbursement shall be paid from the date of placement up to,
Weld County Addendum to the CWS-7A
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
I. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. Provider shall be notified by Department staff of the
date and time of the utilization review.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
2
Weld County Addendum to the CWS-7A
4. To schedule physical and dental examinations within 24 hours after a child is placed in
provider's care. Medical examinations need to be completed within 14 days and dental
examinations need to be completed within 8 weeks of the child being placed with
Provider. All documentation of these examinations will be placed in the foster child's
placement binder.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
7. To maintain, access and review information weekly on the Foster Parents Internet
Database On-line System (FIDOS).
8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. To maintain/update information in the foster child's binder. The binder will be reviewed
on a monthly basis and signed off by child's caseworker and/or the provider's Foster
Care Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child.
11. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment:
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week
02) 3-4 round trips a week.
❑3%:) 7 round trips or more
Comments: _
❑1) One round trip a week ❑1'/) 2 round trips a week
❑2%) 5 round trips a week 03) 6 round trips a week
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
O Basic Maint.) No participation required
❑2) Three times a month
❑3'/) Three times a week or more
Comments:
❑1) Once a month ❑1'/:) Two times month
02%) Once a week ❑3) Two times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular o
special education plan?
❑ Basic Maint.) No educational requirements ❑1) Less than a''/3 hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day ❑2 %:) 1'h-2 hours per day 03) 2'%-3 hours per day
03%) More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week ❑1%) 5 to 7 hours per week 02) F
to 10 hours per week 02%) 11 to 14 hours per week
0 3) Constant basis during awake hours 03%) Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedir
bathing, grooming, physical, and/or occupational therapy?
0 Basic Maint.) 0-2 hours per week
02) 8 to 10 hours per week
❑3/) 21 or more hours per week
Comments:
❑1) 3 to 4 hours per week ❑1'/) 5 to 7 hours per week
❑2/) 11 to 15 hours per week ❑3) 16 to 20 per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑ Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01) Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%) Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention.
❑2'/) Face-to-face contact three times per month with child and occasional crisis intervention.
❑ 3) Face-to-face contact weekly with child and occasional crisis intervention.
❑3%,) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
00) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month
❑2) 4-8 hours per month ❑3) 9-12 hours per month
4 Weld County Addendum to the CWS-
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
Aggression/Cruelty to
Animals
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions
:::: Check one boa for each Cate o ::.. :.:-.........................................................:..:.
i
g r3')
........ . . ..
Mild/
Moderate.
1 1/2
Moderate
2
Moderate/ =`
Ham,`
21/2
Verbal or Physical
Threatening
CI
Destructive of
Property/Fire Setting
111
CI
CI
Stealing
CI
CI
Self -injurious Behavior
CI
CI
Cl
Substance Abuse
CI
Presence of Psychiatric
Symptoms/Conditions
Cl
CI
Enuresis/Encopresis
Runaway
CI
CI
o
Sexual Offenses
CI
CI
111
CI
5
Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Inappropriate Sexual
Behavior
Mild
Ra lg Of C# nditi01f5i ...
.......:............... ... .......
(C eclt.:and;�o�.fob.each;categot3!):::.:::::::.::::::::::: � ��<::::::.-:.�.�......:.:::::.:.:�: �'�:_ �::_:-:::L:::::::,:._::.::
............
Moderate.'``
1 1/2
o
Mode:; • •,;.
High
2 1/2
Hrgh
3
GI
Disruptive Behavior
Delinquent Behavior
CI
Depressive -like Behavior
o
Medical Needs
(If condition is rated "severe",
please complete the Medcally
fragile NBC)
Emancipation
o
Eating Problems
CI
CI
Boundary Issues
Requires Night Care
Education
Involvement with Child's
Family
CI
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ l E 11/2 ❑ 2 ❑ 2% ❑ 3 ❑ 3'/2
6
Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
LEVEL OF SERVICE
County Basic
Maintenance
Rate
Age 0-10...$16.32/day ($496/month)
Age 11-14..$18.05/day (5549/month)
Age 15-21...$19.27/day ($586/month)
+ Respite Care $.66/day ($20/month)
1
$19.73
+$.66 Respite Care
Total Rate = ($20.39 day/$620 month)
1 1/2
$23.01
+$.66 Respite Care
Total Rate = ($23.67 day/S720 month)
2
$26.30
+$.66 Respite Care
Total Rate = ($26.96 day/$820 month)
2 1/2
$29.59
+$.66 Respite Care
Total Rate = ($30.25 day/$920 month)
3
$32.88
+$.66 Respite Care
Total Rate = (S33.54day/$1020 month)
3 1/2
$36.16
+$.66 Respite Care
Total Rate = ($36.82 day/$1.120 month)
4
TRCCF Drop Down
$39.45
+S.66 Respite Care
Total Rate = ($40.11 day/$1220 month)
Assessment/Emergency
Rate
(30 day max)
$30 25 day/$920 month (Includes Respite)
Effective 7/1/2008
7 Weld County Addendum to the CWS-
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:
gai/
Deputy irk to th`Board::
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
Chair Signature
AUG 2 4 2009
PROVIDER
Mark & Susan Andrews
22305 CR 76
Eaton, Colorado 80615
8
Weld County Addendum to the CWS-7A
0 9 -�.�(^�
J 1
CWS-7A S -7A (K10-10/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date G y and between
the Board of Weld County Commissioners, sitting as the oard So ial Service , on behalf of
the Weld County Department of Human Services, hereinafter c Iled "County Department" and,
«MARK & SUSAN ANDREWS », Provider ID#1559384, «22305 CR 76, ((EATON, COLORADO
80615 », hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until
June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24 -hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
CWS-7A S -7A (R1U-10/99)
U- l U/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on -going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out -of -home provider.
2
C W S -7A (K1U-10/99)
U- I U/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to
B
Deputy , erk to the
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature AUG 2 4 2009
PROVIDER
«Mark & Susan Andrews »
«22305 CR 76 »
«Eaton, Colorado 80615»
By/
By:
3
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Paulsen, Larry and Helen
and the
Weld County Department of Human Services
for the period from June 16, 2009 through June 30, 2010.
The following provisions, made this 151kday of . � , 2009, are added to the referenced
Agreement. Except as modified hereby, all terms the Agreement remain unchanged.
GENERAL PROVISIONS
County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre -adoptive
placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#42268. These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
C. Placement service reimbursement shall be paid from the date of placement up to,
t
Weld County Addendum to the CWS-7A
q%GY a� a7
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. Provider shall be notified by Department staff of the
date and time of the utilization review.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
2 Weld County Addendum to the CWS-7A
4. To schedule physical and dental examinations within 24 hours after a child is placed in
provider's care. Medical examinations need to be completed within 14 days and dental
examinations need to be completed within 8 weeks of the child being placed with
Provider. All documentation of these examinations will be placed in the foster child's
placement binder.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
7. To maintain, access and review information weekly on the Foster Parents Internet
Database On-line System (FIDOS).
8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. To maintain/update information in the foster child's binder. The binder will be reviewed
on a monthly basis and signed off by child's caseworker and/or the provider's Foster
Care Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child.
11. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week
❑2) 3-4 round trips a week.
❑3%) 7 round trips or more
Comments:
01) One round trip a week 01%) 2 round trips a week
O2%) 5 round trips a week O3) 6 round trips a week
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.) No participation required
O2) Three times a month
❑3'/) Three times a week or more
Comments:
❑1) Once a month ❑1') Two times month
❑2%) Once a week ❑3) Two times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
O Basic Maint.) No educational requirements
❑2) 1 hour a day
❑3%) More that 3 hours per day
Comments:
01) Less than a /2 hour per day ❑1%)% hour aday
O2 '/:) 1'/:-2 hours per day O3) 2'/,-3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
O Basic Maint.) No special involvement needed O1) Less than 5 hours per week O1%) 5 to 7 hours per week O2) 8
to 10 hours per week O2%) 11 to 14 hours per week
0 3) Constant basis during awake hours O3%) Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin
bathing, grooming, physical, and/or occupational therapy?
O Basic Maint.) 0-2 hours per week
O2) 8 to 10 hours per week
O3%) 21 or more hours per week
Comments:
01) 3 to 4 hours per week 01%) 5 to 7 hours per week
O2%) 11 to 15 hours per week ❑3) 16 to 20 per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01) Face-to-face contact one time per month with child and minimal crisis intervention.
01%) Face-to-face contact one time per month with child and occasional crisis intervention.
O2) Face-to-face contact two times per month with child and occasional crisis intervention.
O2%) Face-to-face contact three times per month with child and occasional crisis intervention.
O3) Face-to-face contact weekly with child and occasional crisis intervention.
❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
O0) Not needed or provided by another source (i.e. Medicaid) 01) Less than 4 hours per month
❑2) 4-8 hours per month ❑3) 9-12 hours per month
4 Weld County Addendum to the CWS-7.
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
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Aggression/Cruelty to
Animals
❑
❑
❑
❑
❑
❑
■
Verbal or Physical
Threatening
❑
❑
❑
O
❑
❑
•
Destructive of
Property/Fire Setting
❑
❑
❑
❑
❑
❑
■
Stealing
❑
❑
❑
❑
❑
❑
•
Self -injurious Behavior
❑
❑
❑
❑
❑
❑
❑
Substance Abuse
❑
❑
❑
❑
❑
❑
❑
Presence of Psychiatric
Symptoms/Conditions•
❑
❑
❑
❑
❑
❑
Enuresis/Encopresis
❑
❑
❑
❑
❑
❑
❑
Runaway
❑
❑
❑
❑
❑
❑
■
Sexual Offenses
❑
❑
❑
❑
❑
❑
❑
5
Weld County Addendum to the CWS-7
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
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Inappropriate Sexual
Behavior
❑
❑
❑
❑
❑
❑
IN
Disruptive Behavior
❑
❑
❑
❑
❑
❑
❑
Delinquent Behavior
❑
❑
❑
❑
❑
❑
■
Depressive -like Behavior
❑
❑
❑
❑
■
■
■
Medical Needs
(lf condition is rated "severe",
please complete the Meacally
fragile NBC)
❑
❑
❑
❑
❑
❑
.
Emancipation
❑
❑
❑
❑
O
❑
E
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 ❑ 2'/z ❑ 3 ❑ 3'/2
6
Weld County Addendum to the CWS-7
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
LEVEL OF SERVICE
................................
.....................................
Level
County Basic
Maintenance
Rate
1
Age 0-10...$16.32/day ($496/month)
Age 11-14...$18.05/day ($549/month)
Age 15-21...$19.27/day ($586/month)
+ Respite Care $.66/day ($20/month)
$19.73
+$.66 Respite Care
Total Rate = ($20.39 day/$620 month)
1 1/2
$23.01
+$.66 Respite Care
Total Rate = ($23.67 day/$720 month)
2
$26.30
+$.66 Respite Care
Total Rate = ($26.96 day/$820 month)
2 1/2
$29.59
+$.66 Respite Care
Total Rate = ($30.25 day/$920 month)
3
$32.88
+$.66 Respite Care
Total Rate = ($33.54day/$1020 month)
3 1/2
$36.16
+$.66 Respite Care
Total Rate = ($36.82 day/$1,120 month)
4
TRCCF Drop Down
$39.45
+$.66 Respite Care
Total Rate = ($40.11 day/$1220 month)
Assessment/Emergency
Rate
(30 day max)
$30.25 day/$920 month (Includes Respite)
Effective 7/1/2008
7
Weld County Addendum to the CWS-7
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board
B
Mida
Deputy Jerk to th
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
AUG 2 4 2009
PROVIDER
«Larry & Helen Paulsen
«1939 Homestead Rd.»
«Greeley, Colorado 80634»
By: OW
By:
C_
8
(7A9
Weld County Addendum to the CW -7A
CWS-7A (R10-10/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date //!1� LC -7W7 by and between
the Board of Weld County Commissioners, sitting as the oard of Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Paulsen, Larry and Helen, Provider ID# 42268, 1939 Homestead Rd., Greeley, CO, 80634,
hereinafter called "Provider."
2. This Contract and Agreement shall be effective from June 16, 2009 and continue in force until
June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24 -hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
C W S-7 A (1110-10/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on -going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out -of -home provider.
2
C W S -7A (RIO -10/99)
To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
PROVIDER
«LARRY & HELEN PAULSEN
1939 Homestead Rd. »
Greeley, Colorado 80634»
>>
AUG 2 4 2009
3
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Schmidt, Donald and Constance
and the
Weld County Department of Human Services
for the period from June 12, 2009 through June 30, 2009.
The following provisions, made this ; day of
Agreement. Except as modified hereby, all terms of theAgreement remain unchanged.
, 2009, are added to the referenced
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre -adoptive
placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1511343. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
4d'l-.%.%,-
Weld County Addendum to the CWS-7A
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3
Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME
WORKER COMPLETING ASSESSMENT
STATE IDt/
SEX TRAILS CASE ID DOB
M F I I
HEW 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 whith most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
Basic Maint.) Less than one round trip a week
❑2) 3-4 round trips a week.
❑3'/:) 7 round trips or more
❑1) One round trip a week ❑1'A) 2 round trips a week
❑2',4) 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?
9 Basic Maint.) No participation required
92) Three times a month
❑3'/) Three times a week or more
❑ 1) Once a month 011/2) Two times month
02%) Once a week ❑3) Two times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular o
special education plan?
9 Basic Maint.) No educational requirements
❑2) I hour a day
❑31A) More that 3 hours per day
91) Less than a'/: hour per day 011/2) 1/2 hour a day
92 %s) 1'/z-2 hours per day 93) 2'/z-3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
9 Basic Maint.) No special involvement needed
❑2) 8 to 10 hours per week
❑ 3) Constant basis during awake hours
DI) Less than 5 hours per week
❑2%:) 11 to 14 hours per week
❑3'A) Nighttime hours
❑1%) 5 to 7 hours per week
P 5. How much time is the provider required to assist the child because of impairments beyond a¢e appropriate needs with feedii
bathing, grooming, physical, and/or occupational therapy?
9 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 ❑2A) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3'h) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑ Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01) Face-to-face contact one time per month with child and minimal crisis intervention.
01%) Face-to-face contact one time per month with child and occasional crisis intervention.
❑ 2) Face-to-face contact two times per month with child and occasional crisis intervention.
02%) Face-to-face contact three times per month with child and occasional crisis intervention.
93) 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 I. 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)
92) 4-8 hours per month
❑1) Less than 4 hours per month
❑3) 9-12 hours per month
4 Weld County Addendum to the CWS-
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
Please rate the behavior/intensity
essinent Areas
None -'
Aggression/Cruelty to Animals
BEHAVIOR ASSESSMENT
of conditions which create the need for services that apply
Rating of Conditions !:
leek one box for each category
Verbal or Physical Threatening
Destructive of Property/Fire
Setting
CI
CI
Stealing
111
Self -injurious Behavior
Substance Abuse
111
Presence of Psychiatric
Symptoms/Conditions
CI
111
Enuresis/Encopresis
Runaway
CI
Sexual Offenses
CI
5
Weld County Addendum to the CWS-
Inappropriate Sexual Behavior
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions
(Check one box for each category)
Severe
3
;omments
Disruptive Behavior
Delinquent Behavior
Depressive -like Behavior
Medical Needs
(If condition is rated "severe", please complete
the Medically fragile NBC)
Emancipation
Eating Problems
Boundary Issues
Requires Night Care
Education
Involvement with Child's Family
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6
Weld County Addendum to the CWS-
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
LEVEL OF
SERVICE
County Basic
Maint.
Age 0-10... $16.32/day ($496/month)
Age 1 1-14...$18.05/day ($549/month)
Age 15-21...$19.27/day ($586/month)
+ Respite Care $.66/day ($20/month)
1
S19.73
+$.66 Respite Care
Total Rate = ($20.39 day/5620 month)
1 112
$23.01
+$.66 Respite Care
Total Rate = ($23.67 day/$720 month)
2
$26.30
+$.66 Respite Care
Total Rate = ($26.96 day/$820 month)
2 1/2
$29.59
+5.66 Respite Care
Total Rate = ($30.25 day/$920 month)
3
$32.88
+5.66 Respite Care
Total Rate = ($33.54day/$1020 month)
3 1/2
$36.16
+5.66 Respite Care
Total Rate = ($36.82 day/$1,120 month)
4
TRCCF Drop Down
$39.45
+$.66 Respite Care
Total Rate = ($40.11 day/$1220 month)
rf.
Assessment Rate
(30 day max)
$30 25 day/$920 month (Includes Respite)
Effective 7/1/2008
7
Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
By:
Weld County CJ kto-e Board
WELD COUNTY BOARD OF
HUMAN SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF HUMAN
SERVICES
By: //i2�9!% L 1
Deputy Cl rk to the Board Chair Signature
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
AUG 2 4 2009
PROVIDER:
Donald & Constance Schmidt
4306 W. 30th St. Rd.
Greeley, Colorado 80634
8
Weld County Addendum to the CWS-7A
CWS-7A (R10-10/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date 7,f/�q, d _WOO9 by and between
the Board of Weld County Commissioners, sitting as the BoardA Human Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
Schmidt, Donald and Constance, Provider ID#1511343, 4306 W. 30th St. Rd., Greeley, CO
80634, hereinafter called "Provider."
2. This Contract and Agreement shall be effective from June 12, 2009 and continue in force until
June 30, 2009 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24 -hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
3700
CWS-7A (R10-10/99)
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on -going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out -of -home provider.
2
CWS-7A (RI0-10/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
Weld County Department of Human Services
County Department - provider Name (type or print)
C
B-
Provider Signature
Date / f F. r-- _ Date
Chairmen, Board of County Commissh
V.;r_LD COUNTY CLERK TO THE
a
to -;?,q,
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Schmidt, Donald and Constance
and the
Weld County Department of Human Services
for the period from July 1, 2009 through June 30, 2010.
The following provisions, made this oV day of i-1111/S/1", 2009, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre -adoptive
placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1511343. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
C. Placement service reimbursement shall be paid from the date of placement up to,
t
Weld County Addendum to the CWS-7A
tpoo9-,a.
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
I. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. Provider shall be notified by Department staff of the
date and time of the utilization review.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
2 Weld County Addendum to the CWS-7A
To schedule physical and dental examinations within 24 hours after a child is placed in
provider's care. Medical examinations need to be completed within 14 days and dental
examinations need to be completed within 8 weeks of the child being placed with
Provider. All documentation of these examinations will be placed in the foster child's
placement binder.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
7. To maintain, access and review information weekly on the Foster Parents Internet
Database On-line System (FIDOS).
8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. To maintain/update information in the foster child's binder. The binder will be reviewed
on a monthly basis and signed off by child's caseworker and/or the provider's Foster
Care Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child.
11. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week
O2) 3-4 round trips a week.
O3%) 7 round trips or more
Comments:
❑ 1) One round trip a week 01%) 2 round trips a week
O2%) 5 round trips a week O3) 6 round trips a week
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.) No participation required
O2) Three times a month
❑3'/z) Three times a week or more
Comments:
❑1) Once a month 01%) Two times month
O2%) Once a week O3) Two times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.) No educational requirements ❑1) Less than a %3 hour per day ❑1%) %2 hour a day
O2) 1 hour a day O2 %z) 1'/z-2 hours per day O3) 2'/z-3 hours per day
❑3'/z) More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week O2) 8
to 10 hours per week ❑2Yz) 11 to 14 hours per week
❑ 3) Constant basis during awake hours O3%) Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin
bathing, grooming, physical, and/or occupational therapy?
❑ Basic Maint.) 0-2 hours per week
O2) 8 to 10 hours per week
O3%) 21 or more hours per week
Comments:
❑1) 3 to 4 hours per week ❑1 %a) 5 to 7 hours per week
O2%) 11 to 15 hours per week O3) 16 to 20 per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
01%) Face-to-face contact one time per month with child and occasional crisis intervention.
O2) Face-to-face contact two times per month with child and occasional crisis intervention.
O2%) Face-to-face contact three times per month with child and occasional crisis intervention.
O3) Face-to-face contact weekly with child and occasional crisis intervention.
O3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0) Not needed or provided by another source (i.e. Medicaid) ❑1) Less than 4 hours per month
❑2) 4-8 hours per month ❑3) 9-12 hours per month
4 Weld County Addendum to the CWS-7
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
Verbal or Physical
Threatening
Destructive of
Property/Fire Setting
Stealing
Self -injurious Behavior
Substance Abuse
Presence of Psychiatric
Symptoms/Conditions
Enuresis/Encopresis
Runaway
Sexual Offenses
5
Weld County Addendum to the CW S-7
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child.
Inappropriate Sexual
Behavior
Disruptive Behavior
Delinquent Behavior
Depressive -like Behavior
Medical Needs
(If condition is rated "severe",
please complete the Medically
fragile NBC)
Emancipation
Eating Problems
Boundary Issues
Requires Night Care
Education
Involvement with Child's
Family
0
0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑i ❑ 1'/2 ❑ 2 ❑ 2'h ❑ 3 ❑ 3'h
6
Weld County Addendum to the CWS-i
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
/50,e 0-10...$16.32/da $496/month
County Basic
Maintenance
Rate
1
1 1/2
2
2 1/2
3
3 1/2
4
TRCCF Drop Down
Assessment/Emergency
Rate
(30 day max)
A.e 11-14...$18.05/da $549/month
A.e 15-21...$19.27/da $586/month
+ Respite Care $.66/da $20/month
$19.73
+$.66 Respite Care
Total Rate = ($20.39 day/$620 month)
$23.01
+$.66 Respite Care
Total Rate = ($23.67 day/$720 month)
$26.30
+$.66 Respite Care
Total Rate = ($26.96 day/$820 month)
$29.59
+$.66 Respite Care
Total Rate = ($30.25 day/$920 month)
$32.88
+$.66 Respite Care
Total Rate = ($33.54day/$1020 month)
$36.16
4.66 Respite Care
Total Rate = ($36.82 day/$1,120 month)
$39.45
4.66 Respite Care
Total Rate = ($40.11 day/$1220 month)
$30.25 day/$920 month (Includes Respite)
Effective 7/1/2008
7
Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board
By:
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
AUG 2 4 2009
PROVIDER
Schmidt, Donald and Constance
4306 W. 30th St Rd
Greeley, CO 80634
8
Weld County Addendum to the CWS-7A 2
1
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
id, CARE FACILITY AGREEMENT
ti
1. THIS CONTRACT AND AGREEMENT, made this date, lt�/ RV, a005 by and between
the Bad of Weld County Commissioners, sitting as the Board of Social Services, on behalf of
the yip County Department of Human Services, hereinafter called "County Department" and,
Sidt, Donald and Constance, Provider ID#1511343, 4306 W. 30th St Rd, Greeley, CO
80484, hereinafter called "Provider."
2. This Contract and Agreement shall be effective from July 1, 2009 and continue in force until
June 30, 2010 or until the facility certificate is revoked or surrendered. This contract and
agreement may be renewed at any time during the term of the valid facility certificate. This
contract and agreement is in lieu of and supersedes all prior purchase contracts between the
parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24 -hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on -going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out -of -home provider.
2
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11.
12.
13.
14.
To invite the provider to Administrative Reviews for Children in placement.
To incorporate provider information in planning for the child.
To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to
B
Deputy (erk to the Soars
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
rd
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
PROVIDER
Schmidt, Donald and Constance
4306 W. 30th St Rd
Greeley, CO 80634
By:
By:
AUG 2 4 2009
3
c2Co 2-;'d.3y
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
AMY & DAVID WARNER
and the
Weld County Department of Human Services
for the period fromlc-(1{ o 3 through June 30, 2010.
The following provisions, made this I y day of 20&1 are added to the referenced
Agreement. Except as modified hereby, all terms of the remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre -adoptive
placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider ID#
1555239. These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five (25) calendar days of
the month following service, it may result in forfeiture of payment.
C. Placement service reimbursement shall be paid from the date of placement up to,
Weld County Addendum to the CWS-7A2
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. Any other
special request for transportation reimbursement shall require prior approval by
the Service Utilization Unit Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. Provider shall be notified by Department staff of the
date and time of the utilization review.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Care Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
2
Weld County Addendum to the CWS-7A
4. To schedule physical and dental examinations within 24 hours after a child is placed in
provider's care. Medical examinations need to be completed within 14 days and dental
examinations need to be completed within 8 weeks of the child being placed with
Provider. All documentation of these examinations will be placed in the foster child's
placement binder.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
7. To maintain, access and review information weekly on the Foster Parents Internet
Database On-line System (FIDOS).
8. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. To maintain/update information in the foster child's binder. The binder will be reviewed
on a monthly basis and signed off by child's caseworker and/or the provider's Foster
Care Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child.
11. Comply with all County and State certification requirements as set forth in the State
Department rules, Staff Manual Volume VII and the Weld County Department of Human
Services Policy and Procedure manual.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below, please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week
❑2) 3-4 round trips a week.
❑3'/z) 7 round trips or more
Comments:
❑ 1) One round trip a week 01%) 2 round trips a week
❑2%z) 5 round trips a week 03) 6 round trips a week
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.) No participation required
02) Three times a month
❑3%) Three times a week or more
Comments:
01) Once a month ❑1'/) Two times month
❑2''/) Once a week 03) Two times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular o
special education plan?
0 Basic Maint.) No educational requirements
02) 1 hour a day
❑3'/z) More that 3 hours per day
Comments:
❑1)Less than a'/:hour per day ❑1%:)'/2hour aday
❑2' 'A) 1'/z-2 hours per day 03) 2'/z-3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week ❑1'/:) 5 to 7 hours per week 02)
to 10 hours per week ❑2%z) 11 to 14 hours per week
❑ 3) Constant basis during awake hours ❑3%z) Nighttime hours
Comments:
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedii
bathing, grooming, physical, and/or occupational therapy?
0 Basic Maint.) 0-2 hours per week
02) 8 to 10 hours per week
❑3'/) 21 or more hours per week
Comments:
❑1) 3 to 4 hours per week ❑1'/z) 5 to 7 hours per week
❑2'/z) 11 to 15 hours per week ❑3) 16 to 20 per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01) Face-to-face contact one time per month with child and minimal crisis intervention.
011/2) Face-to-face contact one time per month with child and occasional crisis intervention.
02) Face-to-face contact two times per month with child and occasional crisis intervention.
❑2'%) Face-to-face contact three times per month with child and occasional crisis intervention.
03) Face-to-face contact weekly with child and occasional crisis intervention.
❑3%z) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive
coordination of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
00) Not needed or provided by another source (i.e. Medicaid) O1) Less than 4 hours per month
❑2) 4-8 hours per month ❑3) 9-12 hours per month
4 Weld County Addendum to the CWS
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions
(Check one box for each category)
Aggression/Cruelty to
Animals
Assessment Areas
Verbal or Physical
Threatening
CI
Destructive of
Property/Fire Setting
CI
Stealing
Self -injurious Behavior
Substance Abuse
Presence of Psychiatric
Symptoms/Conditions
Enuresis/Encopresis
Runaway
Sexual Offenses
5
Weld County Addendum to the CWf
BEHAVIOR ASSESSMENT CONTINUED
Inappropriate Sexual
Behavior
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions
(Check one box for each category)
Mild/.
Moderates
1 1/2
Modera
2
Moderate/
that
2 1/2
CI
Disruptive Behavior
Delinquent Behavior
Depressive -like Behavior
CI
CI
o
Medical Needs
(If condition is rated "severe",
please complete the Medcally
fragile NBC)
Emancipation
❑
❑
Eating Problems
CI
CI
Boundary Issues
CI
CI
Requires Night Care
Education
Involvement with Child's
Family
CI
o
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'/z ❑ 2 ❑ 2'/2 ❑ 3 ❑ 3'/z
6 Weld County Addendum to the CWS
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
LEVELOF SERVICE.::'
RECOMMENDED
PROVIDER:: RATE
P1;-. PS
County Basic
Maintenance
Rate
1
Age 0-10...$16.32/day ($496/month)
Age 11-14...$18.05/day ($549/month)
Age 15-21... $19.27/day ($586/month)
+ Respite Care $.66/day ($20/month)
$19.73
+$.66 Respite Care
Total Rate = ($20.39 day/$620 month)
1 1/2
$23.01
+$.66 Respite Care
Total Rate = (S23.67 day/$720 month)
2
$26.30
+$.66 Respite Care
Total Rate = ($26.96 day/$820 month)
2 1/2
$29.59
+$.66 Respite Care
Total Rate = ($30.25 day/S920 month)
3
$32.88
+$.66 Respite Care
Total Rate = ($33.54day/$1020 month)
3 1/2
$36.16
+$.66 Respite Care
Total Rate = ($36 82 day/$1 ,120 month)
4
TRCCF Drop Down
$39.45
+$.66 Respite Care
Total Rate = ($40.11 day/$1220 month)
iS
i4
:1
Assessment/Emergency
Rate
(30 day max)
$30.25 day/S920 month (Includes Respite)
Effective 7/1/2008
7 Weld County Addendum to the CWS
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Weld County Clerk to the Board
By:
Deputy CWerk to the Board
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
SERVICES
By:
Chair Signature
AUG 2 4 2009
PROVIDER
Amy & David Warner
3424 Pheasant Ct.
Evans, Colorado 80620
By:
By:
8
Weld County Addendum to the CWS-7A
aL"c9- of
CWS-7A S -7A (RI U-10/99)
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
1. THIS CONTRACT AND AGREEMENT, made this date ;Jtti, to, 2839 by and between
the Board of Weld County Commissioners, sitting as the Board f Social Services, on behalf of
the Weld County Department of Human Services, hereinafter called "County Department" and,
AMY & DAVID WARNER, Provider ID# 1555239, 3424 Pheasant Ct., Evans, Colorado
80620, hereinafter called "Provider."
2. This Contract and Agreement shall be effective from Jul 0and continue in force until June
30, 2010 or until the facility certificate is revoked or surrendered. This contract and agreement
may be renewed at any time during the term of the valid facility certificate. This contract and
agreement is in lieu of and supersedes all prior purchase contracts between the parties hereto
and relating to the services herein described.
3. The Provider holds a valid certificate/license as a Family Foster Home/Emergency Shelter Home.
Such certification standards shall be maintained during the term hereof. The provider has read
and is fully familiar with the Minimum Rules and Regulations for Family Foster Homes issued by
the Colorado Department of Human Services.
4. The County Department may, but shall not be obligated to, purchase foster care services. The
County Department or any duly authorized agent may request such services to be provided to
any child at any time within the limits of the certificate and without prior notice. At such time or as
soon as possible after the acceptance of a child for services, the County Department and the
Provider shall verify foster care placement of each child in writing on the required form, which
shall become an addendum to this contract, subject to all the terms and conditions hereof.
The Provider agrees:
1. To furnish foster care services to eligible children at the established rate based on type of facility
and individual child rates negotiated between the county and the provider.
2. To safely provide the 24 -hour physical care and supervision of each child until removed or until
the agreement is renewed.
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans for children in placement, including visits with their
parents, siblings, and relatives, or transition to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the Department.
10. To allow representatives of the County Department to visit the foster home and to see the child at
any reasonable time.
1
C9C 2 -
C WS -7A (RI U-10/99)
,11. To give the County Department two weeks notice, except in an emergency, to remove a child for
placement elsewhere and to work with the County Department as requested in preparing the child
for the next placement.
12. To provide transportation to the child to enable the utilization of professional services when
necessary. The amount of transportation to be provided will be agreed upon at placement and
may be changed upon mutual agreement of the provider and the County Department, as
recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f Any conflict the child may have with law enforcement, school officials, or other persons in
the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or supervising
agency.
i. Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964, Section 504, Rehabilitation Act of 1973, and the ADA
of 1990, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs,
national origin, or handicap.
15. To attend core certification training prior to the placement of any child.
16. To attend on -going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family Homes or Specialized
Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal personnel. The
records shall document the type of care and the term during which care is provided for each child.
In addition, medical, educational, and progress summary records shall be maintained for each
child in accordance with Volume 7 requirements.
21. To maintain medical, dental and educational records for each child/youth and supply updated
information to the County Department.
Department agrees:
1. To share all available information about the child, including relevant social, medical and
educational history, behavior problems, court involvement, parental, sibling and relative visitation
plans, and other specific characteristics of the child, with the provider before placement and to
share additional information when obtained.
2. To inform the provider of expectations regarding the care of the child, such as meeting medical
needs, handling special psychological needs, and separation/loss issues.
3. To arrange for a medical examination of the child before placement or within 14 days after
placement and give a copy of the completed form to the out -of -home provider.
2
CWS-7A S -7A (K I 0-10/99)
4. To give the provider a written record of the child's admission to the home at the time of
placement.
5. To give the provider a written procedure or authorization for obtaining medical care for the child.
6. To involve the provider in service planning for the child as part of the overall treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time of placement or
as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The two-week notice
may be waived by mutual consent to allow immediate removal of said child for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any
situation in which a provider's inability to provide services threatens the health, safety or welfare
of children.
9. To pay the provider at the rates established by the State Department of Human Services or as
negotiated between the provider and the county. The rate of payment per month shall be based
on the type of facility and individual rates. Payment shall be by warrant drawn by the duly
authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve hours of core
certification training for family foster homes. The county department is responsible for providing
information on county specific procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record made thereof
on a case by case basis.
14. To provide notice of hearings.
Additional Agreement regarding a Particular Child:
Please refer to the Weld County Addendum and
the child specific Needs Based Care Addendum to this agreement.
ATTEST: Weld County Clerk to thee Boards.
By: /OiUt
Deputy lerk to the B
Approval as to Substance:
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
WELD COUNTY BOARD OF SOCIAL
SERVICES, ON BEHALF OF THE WELD
COUNTY DEPARTMENT OF HUMAN
Al SERVICES
•
Y }.
.`1 1
J By:
Chair Signature
PROVIDER
Amy & David Warner
3424 Pheasant Ct.
Evans, Colorado 80620
AUG 2 4 2009
3
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