The URL can be used to link to this page

Browse Search

Home My WebLink About20090192MEMORANDUM DATE: January 19, 2009 TO: William F. Garcia, Chair, Board of County Commissioners FROM: • Judy A. Griego, Director, Human Service epai�tl` COLORADO RE: t�l Addendums to Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Services between the Weld County Department of Human Services and Various Providers for Consent Agenda Enclosed for Board approval are Addendums to Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement between the Weld County Department of Human Services and Various Providers. These Agreements were presented at the Board's January 19, 2009, Work Session. The major provisions of these Agreements are: No. Facility Name and Term Type of Facility Location Daily Rate I Burden, Craig and Lea 10/13/08 — 06/30/09 Foster Home Greeley, Colorado $16.32 - $40.11 2 Dickerson, Autumn and Kristian Mathisen, Jr. 12/11/08 — 06/30/09 Foster Home Platteville, Colorado $16.32 - $40.11 3 Hendrix, Samuel and Shanaine 10/29/08 — 06/30/09 Foster Home Firestone, Colorado $16.32 - $40.11 4 Ritter, Thomas and Deborah 12/01/08 — 06/30/09 Foster Home Firestone, Colorado $16.32 - $40.11 5 Wade, Michael and Jodyne 12/01/08 — 06/30/09 Foster Home Windsor, Colorado $16.32 - $40.11 If you have any questions, give me a call at extension 6510. ;LL. C -Y €ik4 AL 7Ckt Ci [(ace 11 . t4 ear -,77—nq 2009-0192 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Burden, Craig and Lea and the Weld County Department of Human Services for the period from October 13, 2008 through June 30, 2009. The following provisions, made this /3/' day of (P, , 2008, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1552261. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall 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. 1 Weld County Addendum to the C W S -7A 6. The Director of Social 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 Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social 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 Social Services and the Provider, or by Social Services as a debt to Social Services or otherwise as provided by law. 7. Provider shall promptly notify Social 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 Social 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 Social Services or Weld County Department of Social 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 ID# ISEX ITRAILS CASE ID NI F DOB H H# IRATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑ Basic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. 03%) 7 round trips or more 01) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month ❑3%) Three times a week or more ❑1) Once a month ❑1Yz) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements 01) Less than a %2 hour per day 01%) '/2 hour a day 02) 1 hour a day 02 %) 1'/2-2 hours per day 03) 2'/r3 hours per day 03%) More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week 0 3) Constant basis during awake hours 03%) Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin, bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week ❑1Y) 5 to 7 hours per week ❑ 2) 8 to 10 hours per week 02%) I 1 to 15 hours per week ❑3) 16 to 20 per week ❑3%) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention. 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. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month ❑1) Less than 4 hours per month 03) 9-12 hours per month Weld County Addendum to the CWS-i 4 WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) 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 El El ❑ El O ❑ O El El 0 O El ❑ El O El O 0 ❑ 0 El El El 5 Weld County Addendum to the CWS-., BEHAVIOR ASSESSMENT CONTINUED (Exhibit B) Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that apply to this child. 0 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues 0 Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 6 Weld County Addendum to the CWS S WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 TRCCF Drop Down Assessment Rate (30 day max) Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS- IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: By: oategidami Weld County Clerk Deputy Cl- - tot e Board (Signature) WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: Czal Chair Signatut`e--- JAN 2 1 2009 William F. Garcia PROVIDER: Craig & Lea Burden 2203 A Street Greeley, Colorado 80634 8 Weld County Addendum to the CWS-7A WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Autumn Dickerson and Kristian Mathisen, Jr. and the Weld County Department of Human Services for the period from December 11, 2008 through June 30, 2009. The following provisions, made this 11th day of December, 2008, 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#1554460. 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. as 9-0/9c Weld County Addendum to the CWS-7A 6. The Director of Social 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 Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social 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 Social Services and the Provider, or by Social Services as a debt to Social Services or otherwise as provided by law. 7. Provider shall promptly notify Social 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 Social 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 Social Services or Weld County Department of Social 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 1 6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook. 7. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 8. To maintain/access information on the Foster Parents Internet Database On-line System (FIDOS) as indicated in the Foster Parent Handbook. 9. To maintain/update information in the Foster Child Placement Information Management binder. The binder may be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Home Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child as indicted in the Foster Parent Handbook. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# ISEX F TRAILS CASE ID 1DOB WORKER COMPLETING ASSESSMENT HH# DATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3') 7 round trips or more 01) One round trip a week ❑1/) 2 round trips a week ❑2'/o 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month ❑3%) Three times a week or more Du Once a month ❑1') Two times month 02%) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements 01) Less than a %3 hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) 11/4-2 hours per day 03) 2'/-3 hours per day 03%) More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours ❑3%) Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) 0Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 011/2) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month ❑1) Less than 4 hours per month ❑3) 9-12 hours per month 4 Weld County Addendum to the CWS-7 WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Aggression/Cruelty to Animals ❑ 0 0 ❑ Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7 BEHAVIOR ASSESSMENT CONTINUED (Exhibit B) Inappropriate Sexual Behavior Please rate the behavio /intensit of conditions which create the need for services that apply to this child. ❑ ❑ 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care 0 Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 6 Weld County Addendum to the CWS S WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 TRCCF Drop Down Assessment Rate (30 day max) Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-7 IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: By: g#4441, Weld County Clerk Deputy Cleft to the Board (Signature) WELD COUNTY DEPARTMENT OF SOCIAL SERVICES B WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: Chair Signature William F. Garcia JAN 2 1 2009 PROVIDER: Autumn Dickerson & Kristian Mathisen, Jr. 5505 WCR 38 Plattev' l , CO 8065' BY: ,1i dia.c.Pat 8 (9m9-O/9c Weld County Addendum to the CWS-7A WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Hendrix, Samuel and Shanaine and the Weld County Department of Human Services for the period from October 29, 2008 through June 30, 2009. The following provisions, made this day of 4.r A , 2008, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1553157. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall 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. eo9- Weld County Addendum to the CWS-7A 6. The Director of Social 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 Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social 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 Social Services and the Provider, or by Social Services as a debt to Social Services or otherwise as provided by law. 7. Provider shall promptly notify Social 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 Social 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 Social Services or Weld County Department of Social 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 To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook. 7. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 8. To maintain/access information on the Foster Parents Internet Database On-line System (FIDOS) as indicated in the Foster Parent Handbook. 9. To maintain/update information in the Foster Child Placement Information Management binder. The binder may be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Home Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child as indicted in the Foster Parent Handbook. EXHIBITS. (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# ISEX F TRAILS CASE ID [DOB WORKER COMPLETING ASSESSMENT HH# [DATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3'/z) 7 round trips or more 01) 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 ❑2) Three times a month ❑3'%z) Three times a week or more ❑1) Once a month 01%) Two times month ❑2'%z) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑2) 1 hour a day 03%) More that 3 hours per day ❑1) Less than a1/2 hour per day ❑1'%z) %z hour a day 02 %) 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 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2'%z) 1 I to 15 hours per week ❑3) 16 to 20 per week 03%) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑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 C WS-; WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that ap •ly to this child. 0 0 ❑ 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7 BEHAVIOR ASSESSMENT CONTINUED (Exhibit B) Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Inappropriate Sexual Behavior Disruptive Behavior 0 0 0 Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation o Eating Problems 0 Boundary Issues Requires Night Care Education 0 Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 6 Weld County Addendum to the CWS-'. WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maint. 1 1 1/2 2 2 1/2 3 3 1/2 4 TRCCF Drop Down Assessment Rate (30 day max) A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Res. ite Care $.66/da $20/month $19.73 4.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 4.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.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 t By: (Signature) WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: Deputy Cleo the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: Chair Signature William F. Garcia PROVIDER: Samuel & Shanaine Hendrix 6606 Tenderfoot Ave. Firestone, Colorado 8050 o`er7,77 By: JAN 2 1 2009 8 Weld County Addendum to the CWS-7A WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Ritter, Thomas and Deborah and the Weld County Department of Human Services for the period from December 1, 2008 through June 30, 2009. The following provisions, made this % ?tday of �,,„„,,L , 2008, 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 determinelevels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1554009. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall 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. &A2 -C/26 Weld County Addendum to the CWS-7A The Director of SS1 Services or designee may exercise tiallowing 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 Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social 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 Social Services and the Provider, or by Social Services as a debt to Social Services or otherwise as provided by law. 7. Provider shall promptly notify Social 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 Social 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 Social Services or Weld County Department of Social 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 To read, be famililaith and agree to the terms and condital as set forth in the Foster Parent Handbook. 7. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 8. To maintain/access information on the Foster Parents Internet Database On-line System (FIDOS) as indicated in the Foster Parent Handbook. 9. To maintain/update information in the Foster Child Placement Information Management binder. The binder may be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Home Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child as indicted in the Foster Parent Handbook. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A IDENTIFYING INFORMATION WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE ID# HH# ISEX TRAILS CASE ID M F I DOB DATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more ❑1) One round trip a week ❑1%z) 2 round trips a week ❑2'/z) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? 9 Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more 01) Once a month 01%) Two times month ❑2%z) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑1) Less than a'' /z hour per day 011/2) 'A hour a day 02) 1 how a day 02 %) 1'/z-2 hours per day 03) 2'A-3 hours per day ❑3'/z) More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.) No special involvement needed ❑l) Less than 5 hours per week ❑1%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week 0 3) Constant basis during awake hours ❑3'A) Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding bathing, grooming, physical, and/or occupational therapy? 0 Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week 92) 8 to 10 hours per week 92%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'A) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑l) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/z) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month 01) Less than 4 hours per month 03) 9-12 hours per month 4 Weld County Addendum to the CWS-7. WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a. ply to this child. 0 ❑ 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7 BEHAVIOR ASSESSMENT CONTINUED (Exhibit B) Please rate the behavior/intensity of conditions which create the need for services that apply 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 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: ❑ 0 O 0 O 0 O 0 ❑ 0 O 0 O 0 O 0 O 0 O 0 (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 6 Weld County Addendum to the CWS-i WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 TRCCF Drop Down Assessment Rate (30 day max) Age 0-10...$16.32/day ($496/month) Age 11-14...$18.05/day ($549/month) Age 15-21...$19.27/day ($586/month) + Respite Care $.66/day ($20/month) $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 4.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 4.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 4.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 4.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the C WS IN WITNESS WHEREChe parties hereto have duly executed •Addendum as of the day, month, and year first above written. ATTEST: By: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: Deputy C rk to the Board Chair Signature William F. Garcia (Signature) WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: JAN 2 1 2009 PROVIDER: 1'60 0 Nieh11 & Deborah Ritter 10136 Deerfield St. Fires ne, Colorado /80520 By: � t. 1' c9a19 - r/2°' 8 Weld County Addendum to the CWS-7A • WELD COUNTY ADDENDUM. To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Jodyne & Michael Wade and the Weld County Department of Human Services for the period from July 1, 2008 through June 30, 2009. The following provisions, made this [ day of SAgothA7, 2008, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre -adoptive placement. Kinship foster care homes and pre -adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1554152. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co -pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall 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. c7al9-n/5 Weld County Addendum to the CWS-7A 6. The Director of SO1 Services or designee may exercise tollowing 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 Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social 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 Social Services and the Provider, or by Social Services as a debt to Social Services or otherwise as provided by law. 7. Provider shall promptly notify Social 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 Social 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 Social Services or Weld County Department of Social 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 famiSwith and agree to the terms and condos as set forth in the Foster Parent Handbook. 7. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 8. To maintain/access information on the Foster Parents Internet Database On-line System (FIDOS) as indicated in the Foster Parent Handbook. 9. To maintain/update information in the Foster Child Placement Information Management binder. The binder may be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Home Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child as indicted in the Foster Parent Handbook. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX F [TRAILS CASE ID IDOB WORKER COMPLETING ASSESSMENT HHt DATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3'A) 7 round trips or more 01) 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 ❑2) Three times a month ❑3'/n) Three times a week or more ❑ 1) Once a month 01%) Two times month ❑ 2%) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑1) Less than a''/x hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %z) 1'/z-2 hours per day 03) 2'/z-3 hours per day ❑3/) More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours ❑3%) Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? 0 Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'%:) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. O 1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month Du Less than 4 hours per month ❑3) 9-12 hours per month Weld County Addendum to the CW S-i 4 WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Self -injurious Behavior Aggression/Cruelty to Animals Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County Addendum to the CWS-7 BEHAVIOR ASSESSMENT CONTINUED (Exhibit B) Please rate the behavior/intensity of conditions which create the need for services that apply to this child. Inappropriate Sexual Behavior Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: o 0 o 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 ❑ 0 O 0 0 o 0 (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 6 Weld County Addendum to the CWS-i WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) A.e 0-10...$16.32/da $496/month County Basic Maint. 1 1 1/2 2 2 1/2 3 31/2 4 TRCCF Drop Down Assessment Rate (30 day max) A.e 11-14...$18.05/da $549/month A.e 15-21...$19.27/da $586/month + Respite Care $.66/da $20/month $19.73 +$.66 Respite Care Total Rate = ($20.39 day/$620 month) $23.01 +$.66 Respite Care Total Rate = ($23.67 day/$720 month) $26.30 +$.66 Respite Care Total Rate = ($26.96 day/$820 month) $29.59 +$.66 Respite Care Total Rate = ($30.25 day/$920 month) $32.88 +$.66 Respite Care Total Rate = ($33.54day/$1020 month) $36.16 +$.66 Respite Care Total Rate = ($36.82 day/$1,120 month) $39.45 +$.66 Respite Care Total Rate = ($40.11 day/$1220 month) $30.25 day/$920 month (Includes Respite) Effective 7/1/2008 7 Weld County Addendum to the CWS-' IN WITNESS WHERE,the parties hereto have duly executed.Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: Add_ By: Deputy " rk to the Board 'Chair Signature William F. Garcia (Signature) WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: PROVIDER: Jodyne & Michael Wade 1016 Cottonwood Dr. Windsor, Colorado 80550 JAN 2 1 2009 8 Weld County Addendum to the CWS-7A Hello