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Home My WebLink About20092496MEMORANDUM elt 0 COLORADO RE DATE: September 17, 2009 TO: William F. Garcia, Chair, Weld County 1?oard of Commissioners FROM: Judy A. Griego, Director, Department ofFi n )ert%l' ?) • Weld County Addendum to the Agreement to Purchase Out -of -Home Placement Services Contracts for Child Placement Agency Services between the Weld County Department of Human Services and Various Contractors to be Placed on the Consent Agenda Enclosed for Board approval are Weld County Addendums to the Agreement to Purchase Out -of -Home Placement Services Contracts for Child Placement Agency Services between the Department and various providers. Please place on the Consent Agenda. Below are the major provisions of the attached Agreements: No. Provider/Term Type of Facility/Location Daily Rate I Arid Child Placement Agency July 1, 2009 — June 30, 2010 Child Placement Agency Wheat Ridge, Colorado $16.32-$40.11 2 Bridges Inc. July 1, 2009 — June 30, 2010 Child Placement Agency Pueblo, Colorado $16.32-$40.11 3 Commonworks D.B.A. Synthesis July 1, 2009 — June 30, 2010 Child Placement Agency Arvada, Colorado $16.32-$40.11 4 Denver Area Youth Services July 1, 2009 — June 30, 2010 Child Placement Agency Denver, Colorado $16.32-$40.11 5 Hope & Home July I, 2009 — June 30, 2010 Child Placement Agency Colorado Springs, Colorado $16.32-$40.11 6 Lost and Found Inc. July I, 2009 - June 30, 2010 Child Placement Agency Wheat Ridge, Colorado $16.32-$40.11 7 Lutheran Family Services of Colorado July 1, 2009 - June 30, 2010 Child Placement Agency Fort Collins, Colorado $16.32-$40.11 8 Maple Star Colorado July 1, 2009 - June 30, 2010 Child Placement Agency Denver, Colorado $16.32-$40.11 9 Savio House July I, 2009 - June 30, 2010 Child Placement Agency Denver, Colorado $16.32-$40.11 10 Special Kids Special Families July 1, 2009 — June 30, 2010 Child Placement Agency Colorado Springs, Colorado $16.32-$40.11 I I Frontier Family Services July 1, 2009 — June 30, 2010 Child Placement Agency_ Longmont, Colorado $16.32-$40.11 12 Imagine July 1, 2009 — June 30, 2010 Child Placement Agency Lafayette, Colorado $16.32-$40.11 13 Smith Agency Inc. July 1, 2009 — June 30, 2010 Child Placement Agency Centennial, Colorado $16.32-$40.11 14 WhimSpire CPA July 1, 2009 — June 30, 2010 Child Placement Agency Montrose, Colorado $16.32-$40.11 I /1 If you ave any -Questions, give me a call at extension 6510. COIL'n-t . , V_ VC) ee.:/+s oeit2q/aei C? C%O 2009-2496 itock" WI`P� COLORADO DEPARTMENT OF HUMAN SERVICES P.O. BOX A GREELEY, CO. 80632 Website: www.co.w eld.co.us Administration and Public Assistance (970) 352-1551 Child Support (970) 352-6933 MEMORANDUM TO: Judy Griego — Director FROM: Lesley Cobb - Child Welfare Rate Negotiator DATE: August 4, 2009 SUBJECT: The Weld County Addendum to the Agreement to Purchase Out -Of -Home Placement Services contracts for Child Placement Agency Services. Attached please find the Weld County Addendum to the Agreement to Purchase Out -Of -Home Placement Service Contracts for Child Placement Agency Services for following providers: Weld County Child Placement Agency Providers 2009-2010 Wheat Ridge, CO 80033-2899 1 Ariel Child Placement Agency 2 Bridges Inc. Commonworks D.B.A. 3 Synthesis 4 Denver Area Youth Services 5 Hope & Home 6 Lost and Found Inc. Lutheran Family Services of 7 Colorado 8 Maple Star Colorado 4251 Kipling St, Unit 500 1225 N Main Street, Suite 102 5310 Ward Road, Suite G-01 1530 W 13th Ave 1925 Dominion Way, Ste 200 6700 W 44th Ave 2032 Lowe Street, Suite 200 2250 S Oneida Street, Suite 100 90205 Pueblo, CO 81003 1980 Arvada, CO 80002 104085 Denver, CO 80204- 2402 45069 Colorado Springs, CO 80918 29867 Wheat Ridge, CO 80033 49489 Fort Collins, CO 80525 45080 Denver, CO 80224- 2557 90967 9 Savio House 325 King Street Denver, CO 80219 37330 Colorado Springs, CO 10 Special Kids Special Families 424 W Pikes Peak Ave 80905 43184 These contracts have been presented for consent approval to the Board of County Commissioners however; I am requesting your signature along with the Boards to complete these contracts for the FY 2009-2010. If you have any questions please call me at Ext. 6441. COLORADO TO: FROM: DATE: SUBJECT: DEPARTMENT OF HUMAN SERVICES P.O. BOX A GREELEY, CO. 80632 Website: www.co.wcld.co.us Administration and Public Assistance (970) 352-1551 Child Support (970) 352-6933 MEMORANDUM Judy Griego — Director Lesley Cobb - Child Welfare Rate Negotiator September 10, 2009 The Weld County Addendum to the Agreement to Purchase Out -Of -Home Placement Services contracts for Child Placement Agency Services. Attached please find the Weld County Addendum to the Agreement to Purchase Out -Of -Home Placement Service Contracts for Child Placement Agency Services for following providers: 1 2 3 4 Frontier Family Services Imagine Smith Agency Inc. WhimSpire CPA Weld County Child Placement Agency Providers 2009-2010 1290 Boston Ave 1400 Dixon Ave 7169 S Liverpool St 309 S Cascade Ave Longmont, CO 80501-5810 Lafayette, CO 80026 Centennial, CO 80016 Montrose, CO 81401 38041 21369 44882 19562 These contracts have been presented for consent approval to the Board of County Commissioners however; I am requesting your signature along with the Boards to complete these contracts for the FY 2009-2010. If you have any questions please call me at Ext. 6441. WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Ariel Child Placement Agency and Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this \ day of _ . , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of a greement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#90205. 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. County and Contractor agree that for Children's Habilitation Residential Program (CHRP) waiver eligible children, the County agrees to pay the federal SSI rate to Contractor and all other service costs will be billable under the CHRP program. 4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 1 Weld County SS -23A Addendum 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. 2 Weld County SS -23A Addendum The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# ISEX F TRAILS CASE ID [DOB WORKER COMPLETING ASSESSMENT HH# IDATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more 01) Once a month 01%) Two times month 02%) Once a week ❑3) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements 01) Less than a %z hour per day 01%) 1/2 hour a day 02) 1 hour a day 02 %) 1'h-2 hours per day 03) 2'A-3 hours per day 03%) More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 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 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month 4 01) Less than 4 hours per month ❑3) 9-12 hours per month Weld County SS -23A Addend,. WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a . . ly to this child. 0 0 0 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 0 Runaway 0 Sexual Offenses 5 Weld County SS -23A Addend'. BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity 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 Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/ ❑ 2 ❑ 2'h ❑ 3 ❑ 31/2 6 Weld County SS -23A Addenda' WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: $6.91 day/$210.00 month Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 +$.66 Respite Care ($20.39 day/$620 mo) $23.01 +$.66 Respite Care ($23.67 day/$720 mo) $26.30 4.66 Respite Care ($26.96 day/$820 mo) $29.59 4.66 Respite Care ($30.25 day/$920 mo) $32.88 4.66 Respite Care ($33.54day/$1020 mo) $36.16 4.66 Respite Care ($36.82 day/$1,120 mo) $39.45 +$.66 Respite Care $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$15omo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2 ...... $9.86 day/$300 mo Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2 $13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2 $16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts .er week minimum. As of 7/01/08 $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ../2.99 Level 2..$4.47 Level 3..$6.02 Level 4....Neg. 7 Weld County SS -23A Addendu IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board ge4/Y-ilLei Bv: Deputy Jerk 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 CONTRACTOR Ariel Child Placement Agency 4251 Kipling St, Unit 500 Wheat Ridge, CO 80033-2899 By: 8 Weld County SS -23A— " 9 WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services .f (the "Agreement") between Bridges Inc. and Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this 1 day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms o hEAgreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#1980. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. dac9-x5122 Weld County SS -23A Addendum 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 2 Weld County SS -23A Addendum 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII — ATTACHMENTS: 3 Weld County SS -23A Addendum WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE IDH HHN SEX [['RAILS CASE ID 1DOB M F I J DATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3'/) 7 round trips or more ❑1) One round trip a week ❑1%z) 2 round trips a week ❑2%z) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required ❑2) Three times a month 03%) Three times a week or more 01) Once a month ❑1%) Two times month ❑2'/z) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑1) Less than a'' /z hour per day 01%) %z hour a day 02) 1 hour a day 02 %) 11/2-2 hours per day 03) 2'/z-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? O Basic Maint.) No special involvement needed ❑2) 8 to 10 hours per week ❑ 3) Constant basis during awake hours ❑l) Less than 5 hours per week ❑1%) 5 to 7 hours per week ❑2%z) 11 to 14 hours per week 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 ❑2) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/z) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month 4 ❑1) Less than 4 hours per month ❑3) 9-12 hours per month Weld County SS -23A Addend, WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ 0 • • Verbal or Physical Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ 0 ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ ❑ ❑ • Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Substance Abuse ❑ ❑ ❑ ❑• • • Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑•❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ • Runaway ❑ ❑ ❑ ❑ ❑ ❑ • Sexual Offenses ❑ ❑ ❑ ❑ ❑ ❑ ❑ 5 Weld County SS -23A Addeni BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a o this child. Inappropriate Sexual Behavior Disruptive Behavior ❑ ❑ ❑ Delinquent Behavior ❑ O ❑ Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: check level of need) ❑ 0 ❑ 1 ❑ 1'h ❑ 2 ❑ 2'/2 ❑ 3 ❑ 3'h 6 Weld County SS -23A Addendu WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: As of 7/01/08 Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 4.66 Respite Care ($20.39 day/$620 mo) $23.01 +$.66 Respite Care ($23.67 day/$720 mo) $26.30 4.66 Respite Care ($26.96 day/$820 mo) $29.59 4.66 Respite Care ($30.25 day/$920 mo) $32.88 4.66 Respite Care ($33.54day/$1020 mo) $36.16 4.66 Respite Care ($36.82 day/$1,120 mo) $39.45 +$.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2$9.86 day/$300 mo Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2.........$13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2 $16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts •er week minimum. $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ...$2.99 Level 2..$4.47 Level 3..$6.02 Level 4....Neg. $6.91 day/$210.00 month 7 Weld County SS -23A Addenda , IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: `/ Chair Signature CONTRACTOR Bridges Inc. 1225 N Main Street, Suite 102 Pueblo, CO 81003 8 Weld County SS -23A Aod�!,5)Y,' / ,' WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Commonworks D.B.A. Synthesis anti -Weld County Department of Human Services for the period from 4.'^ July 1, 2009 through June 30, 2010. • i The following provisions, made this \ day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms o th greement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#104085. 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. County and Contractor agree that for Children's Habilitation Residential Program (CHRP) waiver eligible children, the County agrees to pay the federal SSI rate to Contractor and all other service costs will be billable under the CHRP program. 4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 02 ©D9- X4'94 Weld County SS -23A Addendum 8: Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. 2 Weld County SS -23A Addendum The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE ID# SEX TRAILS CASE ID DOB M F I I HH# IDATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑ Basic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. 03%) 7 round trips or more ❑ 1) One round trip a week ❑1%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more ❑ 1) Once a month 01%) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular oI special education plan? O Basic Maint.) No educational requirements ❑2) 1 hour a day 03%) More that 3 hours per day ❑1) Less than a V2 hour per day O1,A) 1/2 hour a day 02 '/) 11/2-2 hours per day 03) 2%r3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? O Basic Maint.) No special involvement needed 02) 8 to 10 hours per week ❑ 3) Constant basis during awake hours 01) Less than 5 hours per week ❑2%) 11 to 14 hours per week ❑3''/) Nighttime hours 01%) 5 to 7 hours per week P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedir bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑3%) 21 or more hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2%x) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one timeper 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 ❑1) Less than 4 hours per month 03) 9-12 hours per month 4 Weld County SS -23A Addenc WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a . • ly to this child. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening 0 ❑ ❑ ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ • Substance Abuse ❑ ❑ ❑ ❑ ❑ ❑ • Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ 0 ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ■ Runaway ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ 0 ❑ ❑ ❑ 5 Weld County SS -23A Adden< BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ • • Disruptive Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ ❑ ❑ ❑ ❑ In❑ Emancipation ❑ ❑ ❑ ❑ ❑ ❑ • Eating Problems ❑ ❑ ❑ ❑ ❑ ❑ ❑ Boundary Issues ❑ ❑ ❑ ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ■ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'h ❑ 2 ❑ 2'h ❑ 3 ❑ 3'/z 6 Weld County SS -23A Adden, WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: $6.91 day/$210.00 month Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 4.66 Respite Care ($20.39 day/$620 mo) $23.01 4.66 Respite Care ($23.67 day/$720 mo) $26.30 +$.66 Respite Care ($26.96 day/$820 mo) $29.59 4.66 Respite Care ($30.25 day/$920 mo) $32.88 +$.66 Respite Care ($33.54day/$1020 mo) $36.16 +$.66 Respite Care ($36.82 day/$1,120 mo) $39.45 +$.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2 $9.86 day/$300 mo Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2 $13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2 $16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts .er week minimum. As of 7/01/08 $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4.........$14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ...$2.99 Level 2..$4.47 Level 3..$6.02 Level 4....Neg. 7 Weld County SS -23A Addendu IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board LU By: Depu Clei-k 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 c By: mohair Signature CONTRACTOR Commonworks D.B.A. Synthesis 5310 Ward Road, Suite G-01 Arvada, CO 80002 BY: kliaCL 8 01O6 9)—C2/% Weld County SS -23A Addendum WELD COUNTY ADDENDUM ry To that certain Agreement to Purchase Child Placement Agency $trvices (the "Agreement") between Denver Area Youth Services and Weld'Cgynty Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this /5 day of Agreement. Except as modified hereby, all terms bf the Agreement remain unchanged. ii , 2009, are added to the referenced 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#45069. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. Weld County SS -23A en un'i '&4 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may 2 Weld County SS -23A Addendum exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE 11W HH# SEX TRAILS CASE ID M F DOB DATE OF ASSESSMENT AGENCY NAME (PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 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%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month ❑3'/z) Three times a week or more 01) Once a month ❑1%z) 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? O Basic Maint.) No educational requirements ❑2) 1 hour a day 03%) More that 3 hours per day 01) Less than a'' /z hour per day 01%) 1/2 hour a day 02 %) 1'/-2 hours per day 03) 2''/-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 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 01) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'/z) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 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 SS -23A Addend' WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. 0 0 0 ❑ 0 0 0 Verbal or Physical Threatening 0 Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway 0 Sexual Offenses 5 Weld County SS -23A Addendui BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. Inappropriate Sexual Behavior Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care Education Involvement with Child's Family 0 0 0 0 0 ❑ 0 0 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑i ❑ 1% ❑ 2 ❑ 21/2 ❑ 3 ❑ 31 6 Weld County SS -23A Addendu WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: $6.91 day/$210.00 month Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 +$.66 Respite Care ($20.39 day/$620 mo) $23.01 +$.66 Respite Care ($23.67 day/$720 mo) $26.30 +$.66 Respite Care ($26.96 day/$820 mo) $29.59 +$.66 Respite Care ($30.25 day/$920 mo) $32.88 +$.66 Respite Care ($33.54day/$1020 mo) $36.16 +$.66 Respite Care ($36.82 day/$1,120 mo) $39.45 +$.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$15omo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2 $9.86 day/$300 mo Level 2 ................$11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2.........$13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2 $16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts .er week minimum. As of 7/01/08 $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ...$2.99 Level 2..$4.47 Level 3..$6.02 Level 4....Neg. 7 Weld County SS -23A Addendu IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Deputy lerk 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 CONTRACTOR Denver Area Youth Services 1530 W 13th Ave Denver, CO 80204-2402 By. 8 amu -a4y� Weld County SS -23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Hope & Home and Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this 1 day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of he greement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#29867. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 'PO t 411113r) ndu d Weld County SS -23A Ad n�4 - ' 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 2 Weld County SS -23A Addendum ' 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE ID# SM F I EX TRAILS CASE ID IDOB HH# IDATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more ❑ l) Once a month ❑11) Two times month ❑2%:) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular of special education plan? 0 Basic Maint.) No educational requirements ❑2) 1 hour a day ❑3%) More that 3 hours per day ❑1) Less than a'h hour per day ❑1Y) V2 hour a day 02 1/2) 1%:-2 hours per day 03) 2'/-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.) No special involvement needed 02) 8 to 10 hours per week ❑ 3) Constant basis during awake hours ❑ 1) Less than 5 hours per week ❑2%) 11 to 14 hours per week 03%) 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 aae appropriate needs with feedir bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week 02) 8 to 10 hours per week ❑3%) 21 or more hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2'/:) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑ 1'/) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month 4 ❑1) Less than 4 hours per month ❑3) 9-12 hours per month Weld County SS -23A Addem WELD COUNTY IRIS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensi of conditions which create the need for services that a . . ly to this child. 0 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 0 5 Weld County SS -23A Addend BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a..l to this child. 0 0 0 ❑ Inappropriate Sexual Behavior Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) 0 Emancipation Eating Problems Boundary Issues Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1'h ❑ 2 ❑ 2A ❑ 3 ❑ 3/ 6 Weld County SS -23A Addend WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 +$.66 Respite Care ($20.39 day/$620 mo) $23.01 +$.66 Respite Care ($23.67 day/$720 mo) $26.30 +$.66 Respite Care ($26.96 day/$820 mo) $29.59 +$.66 Respite Care ($30.25 day/$920 mo) $32.88 +$.66 Respite Care $36.16 4.66 Respite Care ($36.82 day/$1,120 mo) $39.45 +$.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2 $9.86 day/$300 mo Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2.........$13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2 $16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts .er week minimum. $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ...$2.99 Level 2..$4.47 Level 3..$6.02 Level 4....Neg. As of 7/01/0E $6.91 day/$210.00 month 7 Weld County SS -23A Addend IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature CONTRACTOR Hope & Home 1925 Dominion Way, Ste 200 Colorado Springs, CO 80918 By: /17/ ; ) G 8 C� X95 Weld County SS -23A A dendu� � � WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Lost and Found Inc. and Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this \ day of Agreement. Except as modified hereby, all terms otlth6J`Agreement remain unchanged. , 2009, are added to the referenced 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#57351. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. amp -07`/26 Weld County SS -23A Addendum 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 2 Weld County SS -23A Addendum 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may . exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE ID# SEX 'TRAILS CASE ID IDOB M F I II WI IDATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more ❑1) One round trip a week ❑1%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required ❑2) Three times a month ❑3%z) Three times a week or more ❑l) Once a month ❑1%) Two times month ❑2'/) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? 0 Basic Maint.) No educational requirements ❑2) 1 hour a day ❑3'/) More that 3 hours per day DI) Less than a %x hour per day 011/2) 1/2 hour a day 02 %) 1'/r2 hours per day 03) 2'/2-3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑i) Less than 5 hours per week ❑1%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week ❑1/) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑ Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑ 1/) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) ❑2) 4-8 hours per month ❑1) Less than 4 hours per month ❑3) 9-12 hours per month Weld County SS -23A Addendt 4 WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Aggression/Cruelty to Animals Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 0 0 0 5 Weld County SS -23A Addendu BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensity of conditions which create the need for services that a t t 1 to this child. Inappropriate Sexual Behavior Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ i ❑ PA ❑ 2 ❑ 2/ ❑ 3 ❑ 3'h 6 Weld County SS -23A Addendt WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: $6.91 day/$210.00 month Age 0-10...$16.32 ($496) Age 11-14../18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 +$.66 Respite Care ($20.39 day/$620 mo) $23.01 4.66 Respite Care ($23.67 day/$720 mo) $26.30 +$.66 Respite Care ($26.96 day/$820 mo) $29.59 4.66 Respite Care ($30.25 day/$920 mo) $32.88 +$.66 Respite Care ($33.54day/$1020 mo) $36.16 4.66 Respite Care ($36.82 day/$1,120 mo) $39.45 4.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2 $9.86 day/$300 mo Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2.........$13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2 $16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts .er week minimum. As of 7/01/08 $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ...$2.99 Level 2..$4.47 Level 3..$6.02 Level 4....Neg. 7 Weld County SS -23A Addendu IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board /04 • B Deput • Cler 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: (A)17Th hair Signature CONTRACTOR Lost and Found Inc. 6700 44th Ave Wheatridge, CO 80033 8 c�Cb%- aY9 Weld County SS -23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Lutheran Family Services of Colorado and Wia0, County Department of Human Services for the period from', July 1, 2009 through June 30, 2010. The following provisions, made this \ day of Agreement. Except as modified hereby, all terms ofkheagreement remain unchanged. , 2009, are added to the referenced 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#45080. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section 1. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. 0 &V? Weld County 55.23A 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may 2 Weld County SS -23A Addendum exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME WORKER COMPLETING ASSESSMENT STA'T'E ID# HII# SEX TTRAILS CASE ID M F DOB DATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID 4NSWERS 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 El) One round trip a week ❑1%:) 2 round trips a week ❑2'/) 5 round trips a week ❑3) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required E2) Three times a month ❑3%:) Three times a week or more ❑l) Once a month ❑1Y:) 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 o special education plan? E Basic Maint.) No educational requirements ❑ 2) I hour a day ❑3'/:) More that 3 hours per day El) Less than a''/F hour per day ❑l%) / hour a day E2 ''A) 1'/z-2 hours per day ❑3) 29e-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 E2) 8 to 10 hours per week ❑ 3) Constant basis during awake hours El) Less than 5 hours per week ❑2/) 11 to 14 hours per week ❑3'/) Nighttime hours ❑1%) 5 to 7 hours per week P 5. llow much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedit bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑2) 8 to 10 hours per week ❑ 3'/) 21 or more hours per week El) 3 to 4 hours per week ❑ 1%) 5 to 7 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one timeper month with child and minimal crisis intervention. 011/2) 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. ❑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 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) ❑l) Less than 4 hours per month ❑2) 4-8 hours per month E3) 9-12 hours per month 4 Weld County SS -23A Addend 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) Assessment Areas None Mild mud/ Moderate Moderate/ High 3 High/ Comments: Moderate. High 2 1/2 Severe 0 1 1 1/2 2 3 1/2 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑Ell❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ ❑ ❑ ■ Stealing ❑ ❑ ❑ ❑ ❑ ❑ ❑ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Substance Abuse ❑ ❑ ❑ ❑ ❑ ■ ■ Presence of Psychiatric Symptoms/Conditions ❑in❑ ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ . Runaway ❑ ❑ ❑ ❑ ❑ ❑ in Sexual Offenses ❑ ❑ ❑ ❑ ❑ ■ ■ 5 Weld County SS -23A Addend BEHAVIOR ASSESSMENT CONTINUED 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) Assessment Areas None Mild Mild/ Moderate Moderate/ High 3 High/ Severe Comments: Moderate. High 2 1/2 0 1 1 1/2 2 3 1/2 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 ❑ ❑ ❑ ❑ ❑ii❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 1 ❑ 1',2 ❑ 2 ❑ 2'h ❑ 3 3'A 6 Weld County SS -23A Addendu WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) LEVEL OF SERVICE RECOMMENDED PROVIDER RATE P1 - P5 RECOMMENDED AGENCY RATE Al THERAPY RATE T1 MEDICAL NEEDS ADDENDUM Level Rate Case Management (Admin. Maint.) Therapy (Admin. Services) Level County Basic Maint. Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 0...$0 (None) 1 $19.73 +$.66 Respite Care ($20.39 day/$620 mo) Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 1 ...$2.99 1 1/2 $23.01 +$.66 Respite Care ($23.67 day/$720 mo) Level 1 1/2 $9.86 day/$300 mo 2 $26.30 +$.66 Respite Care ($26.96 day/$820 mo) Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 2..$4.47 2 1/2 $29.59 +$.66 Respite Care ($30.25 day/$920 mo) Level 2 1/2 $13.15 day/$400 mo 3 $32.88 +$.66 Respite Care ($33.54day/$1020 mo) Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 3..$6.02 3 1/2 $36.16 +$.66 Respite Care ($36.82 day/$1,120 mo) Level 3 1/2 $16.44 day/$500 mo 4 RTC Drop Down $39.45 +$.66 Respite Care ($40.11 day/$1220 mo) Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts per week minimum. _ Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4.... Neg. Assess/ Emergency Level Rate (30 Day Max) $30.25 day/$920 mo (Includes Respite) $13.15 day/$400 mo Admin. Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS -23A Addend' IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Lan, Deput' Clerk to Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: IfifrG Chair Signature CONTRACTOR Lutheran Family Services of Colorado 363 S. Harlan St uite 200 Denver C B 7/4,?Vi09 8 �9� Weld County SS -23A Ad endii WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Maple Star Colorado and Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this \ day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms of e greement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#90967. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. I 075// Weld County 55-23A dendum 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 . days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 2 Weld County SS -23A Addendum 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII — ATTACHMENTS: 3 Weld County SS -23A Addendum IDENTIFYING INFORMATION WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE IDit HMO SEX 1FRAILS CASE ID IDOB M F DATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑3%) 7 round trips or more ❑1) One round trip a week 01%) 2 round trips a week ❑2Y:) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? O Basic Maint.) No participation required 02) Three times a month ❑3%) 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 '/3 hour per day ❑1%) 'h hour a day 02) 1 hour a day 02 /) 11/2-2 hours per day 03) 2'/r3 hours per day 03%) More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week ❑1%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours ❑3%) Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedini bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%s) 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. Di %) 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. ❑21) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month Du Less than 4 hours per month ❑3) 9-12 hours per month 4 Weld County SS -23A Addendu WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a . • 1 to this child Aggression/Cruelty to Animals Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County SS -23A Addendm BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that a r r 1 to this child. Inappropriate Sexual Behavior 0 ❑ 0 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ i ❑ 11/2 ❑ 2 ❑ 2'/2 ❑ 3 ❑ 3'/2 6 Weld County SS -23A Addend', WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 1 1 1/2 2 3 3 1/2 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: $6.91 day/$210.00 month Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 +$.66 Respite Care ($20.39 day/$620 mo) $23.01 +$.66 Respite Care ($23.67 day/$720 mo) $26.30 +$.66 Respite Care ($26.96 day/$820 mo) $29.59 +$.66 Respite Care ($30.25 day/$920 mo) $32.88 +$.66 Respite Care ($33.54day/$1020 mo) $36.16 +$.66 Respite Care ($36.82 day/$1,120 mo) $39.45 +$.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2 $9.86 day/$300 mo Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2 $13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2 ..... ...$16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts .er week minimum. As of 7/01/08 $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ...$2.99 Level 2..$4.47 Level 3..56.02 Level 4....Neg. 7 Weld County SS -23A Addendui , IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: I Chair Signature CONTRACTOR Maple Star Colorado 2250 S Oneida Street, Suite 100 Denver, CO 80224-2557 8 aan d - 02994 Weld County SS -23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Savio House and Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this \ day of Agreement. Except as modified hereby, all terms oBthcAgreement remain unchanged. , 2009, are added to the referenced 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#37330. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 9 2924 Weld County SS -23A Addendum 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 2 Weld County SS -23A Addendum 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum WELD COUNTY MIS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE ID# HH# SEX [TRAILS CASE ID DOB M F I 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 DI) One round trip a week ❑1%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? 0 Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more 01) Once a month ❑112) 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 oI special education plan? ❑ Basic Maint.) No educational requirements ❑1) Less than a1/2 hour per day 011/2) 1/2 hour a day 02) 1 hour a day 02 %) 1'/r2 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 02) 8 to 10 hours per week ❑ 3) Constant basis during awake hours ❑ 1) Less than 5 hours per week ❑2'/:) 11 to 14 hours per week ❑3'h) Nighttime hours ❑1/) 5 to 7 hours per week P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑l) 3 to 4 hours per week ❑1'/) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1'%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. ❑3'/) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month 4 ❑1) Less than 4 hours per month 03) 9-12 hours per month Weld County SS -23A Addend WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT Aggression/Cruelty to Animals BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child. 0 0 0 0 0 0 Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis 0 0 0 Runaway Sexual Offenses 0 5 Weld County SS -23A Addend BEHAVIOR ASSESSMENT CONTINUED Please rate the behavior/intensit of conditions which create the need for services that apply to this child. Inappropriate Sexual Behavior 0 0 0 ❑ 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 11/2 ❑ 2 ❑ 2'h ❑ 3 ❑ 31/2 6 Weld County SS -23A Addend WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 4.66 Respite Care $23.01 4.66 Respite Care ($23.67 day/$720 mo) $26.30 4.66 Respite Care ($26.96 day/$820 mo) $29.59 4.66 Respite Care ($30.25 day/$920 mo) $32.88 +$.66 Respite Care ($33.54day/$1020 mo) $36.16 +$.66 Respite Care ($36.82 day/$1,120 mo) $39.45 4.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2 $9.86 day/$300 mo Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2 $13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2 $16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts .er week minimum. $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ...52.99 Level 2..$4.47 Level 3..$6.02 Level 4.... Neg. As of 7/01/0t $6.91 day/$210.00 month 7 Weld County SS -23A Addend IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Mida, Deput lerk 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 CONTRACTOR Savio House 325 King Street Denver, CO 80219 By: 8 Weld County SS -23A Addendum �� endum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services , (the "Agreement") between Special Kids Special Families and Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this \ day of �y , 2009, are added to the referenced Agreement. Except as modified hereby, all terms o t Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#43184. 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. County and Contractor agree that for Children's Habilitation Residential Program (CHRP) waiver eligible children, the County agrees to pay the federal SSI rate to Contractor and all other service costs will be billable under the CHRP program. 4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. -,9924 Weld County SS -23A Addendum 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. 2 Weld County SS -23A Addendum The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum IDENTIFYING INFORMATION WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE ID# SEX TRAILS CASE ID M F DOB HH# ID ATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ['Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. ❑ 3'/) 7 round trips or more ❑1) One round trip a week 01%) 2 round trips a week 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required ❑ 2) Three times a month ❑3%) Three times a week or more ❑1) Once a month 01%) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑l) Less than a''/z hour per day 011/2) %z hour a day ❑2) 1 hour a day 02 %) 11/2-2 hours per day 03) 2%r3 hours per day ❑3'%) More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑l) Less than 5 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours 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 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑l) Face-to-face contact one time per month with child and minimal crisis intervention. ❑1%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month ❑l) Less than 4 hours per month ❑3) 9-12 hours per month Weld County SS -23A Addendu 4 WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Aggression/Cruelty to Animals Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 0 0 0 5 Weld County SS -23A Addendo BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a . . 1 to this child. 0 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑1 ❑ 1% ❑ 2 ❑ 2% O 3 ❑ 3% 6 Weld County SS -23A Addendu WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 +$.66 Respite Care ($20.39 day/$620 mo) $23.01 +$.66 Respite Care ($23.67 day/$720 mo) $26.30 4.66 Respite Care ($26.96 day/$820 mo) $29.59 4.66 Respite Care ($30.25 day/$920 mo) $32.88 4.66 Respite Care ($33.54day/$1020 mo) $36.16 +$.66 Respite Care ($36.82 day/$1,120 mo) $39.45 4.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2.........$9.86 day/$300 mo Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2.........$13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2 $16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts .er week minimum. $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3.........$14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ...$2.99 Level 2..$4.47 Level 3..$6.02 Level 4....Neg. As of 7/01/08 $6.91 day/$210.00 month 7 Weld County SS -23A Addends . IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Deput tClerk 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 CONTRACTOR Special Kids Special Families 424 W Pikes Peak Ave Colorado Springs, By; 8090 8 0,20619- a y94 Weld County SS -23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency lervices '-) (the "Agreement") between Frontier Family Services and Weld Caunty Department of Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this ' day of , 2009, are added to the referenced Agreement. Except as modified hereby, all terms f Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#38041. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. aQ)y- 07096 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE ID# SEX 'TRAILS CASE ID 'DOB M F 1111# 'DATE OF ASSESSMENT AGENCY NAME 'PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? Basic Maint.) Less than one round trip a week ❑2) 3-4 round trips a week. ❑3'/:) 7 round trips or more ❑l) One round trip a week ❑1'/:) 2 round trips a week ❑2%:) 5 round trips a week ❑3) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month ❑3%) 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 ❑2) 1 hour a day ❑3%) More that 3 hours per day ❑1)Less than a%hour per day ❑1%)'%hour aday 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? 0 Basic Maint.) No special involvement needed ❑2) 8 to 10 hours per week 0 3) Constant basis during awake hours ❑ 1) Less than 5 hours per week 02%) 11 to 14 hours per week ❑3%a) Nighttime hours 01%) 5 to 7 hours per week P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week O1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3/) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00) Not needed or provided by another source (i.e. Medicaid) O1) Less than 4 hours per month fl21 4-8 hours ner month ri31 9-12 hours ner month 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) Assessment .Areas tictu 0 1I 1 biltModerate/ Moderate. Moderate > 3 MEW 3 1/2 'comments: High 21/2 1 1/2 2 Aggression/Cruelty to Animals ❑ ❑ O • ■ •❑ Verbal or Physical Threatening ❑ ❑ ❑ ■ ■ ■ • Destructive of Property/Fire Setting O ❑ ❑ ❑ ❑ ■ ■ Stealing ❑ ❑ O ❑ ❑ O ❑ Self -injurious Behavior ❑ ❑ ❑ ❑ ❑ O ■ Substance Abuse ❑ ❑ ❑ ❑ O • ■ Presence of Psychiatric Symptoms/Conditions ❑•❑ ❑ • •❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ ❑ ❑ ■ Runaway ❑ ❑ ❑ ❑ • • ■ Sexual Offenses ❑ O ❑ ❑ ❑ O ❑ BEHAVIOR ASSESSMENT CONTINUED 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) Assessment Areas NM 0 Md 1 AM Modtr$e. Moderate Modem UM 21/2 nig 3 ≥ its 31/2 11/2 2 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Disruptive Behavior ❑ 0 ❑ ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ ❑ ❑ ❑ Depressive -like Behavior ❑ ❑ ❑ ❑ ❑ ❑ ■ Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) ❑ 0 ❑ ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ ❑ • • Eating Problems ❑ ❑ ❑ ❑ ❑ 0 • Boundary Issues ❑ ❑ ❑ 0 ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ ❑ ■ ■ Involvement with Child's Family ❑ ❑ ❑ ❑ ❑ ❑ ❑ CHILD'S OVERALL (check level of need) LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: ❑ 1'/2 ❑ 2 ❑ 2'/2 ❑ 0 ■ 1 ❑ 3 ■ 3'/2 WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) LEVEL OF SERVICE' RECOMMENDED PROVIDER RATE P1 -PS RECOMMENDED AGENCY RATE Al tHERAPY RATE TI MEDICAL NEEDS ADDENDUM.. Leval ;Rate Case Management (Admin. Maint.) T erapY. , (Admin.Services) Level County Basic Maint. Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 0...$0 (None) 1 $19.73 +$.66 Respite Care ($20.39 day/$620 mo) Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 1 ...$2.99 1 1/2 $23.01 +$.66 Respite Care ($23.67 day/$720 mo) Level 1 1/2 $9.86 day/$300 mo ----------------- -------- 2 $26.30 +$.66 Respite Care ($26.96 day/$820 mo) Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 2..$4.47 2 1/2 $29.59 4.66 Respite Care ($30.25 day/$920 mo) Level 2 1/2 $13.15 day/$400 mo -------------------- -------- 3 $32.88 4.66 Respite Care ($33.54day/$1020 mo) Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 3..$6.02 3 1/2 $36.16 4.66 Respite Care ($36.82 day/$1,120 mo) Level 3 1/2 $16.44 day/$500 mo ______ 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) $39.45 +$.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts r week minimum. $13.15 day/$400 mo Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4....Neg. Admin. Overhead Rate: As of 7/01/08 $6.91 day/$210.00 month 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 Deputylerk to Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Zzgi Chair Signature CONTRACTOR Frontier Family Services 1290 Boston Ave Longmont, CO 80501-5810 070g- as19, WELD COUNTY ADDENDUM r., To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Imagine and Weld County Department of ' Human Services for the period from July 1, 2009 through June 30, 2010. The following provisions, made this I day of Agreement. Except as modified hereby, all terms df t Agreement remain unchanged. , 2009, are added to the referenced 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#21369. 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. County and Contractor agree that for Children's Habilitation Residential Program (CHRP) waiver eligible children, the County agrees to pay the federal SSI rate to Contractor and all other service costs will be billable under the CHRP program. 4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 0?OO2'- 9412 Weld County SS -23A Addendum 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed 1EP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. 2 Weld County SS -23A Addendum The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum IDENTIFYING INFORMATION WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE ID# SEX TRAILS CASE ID DOB M F I I Mitt IDATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑ Basic Maint.) Less than one round trip a week 02) 3-4 round trips a week. 03%) 7 round trips or more 01) One round trip a week 01%) 2 round trips a week ❑2%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required ❑2) Three times a month 03%) Three times a week or more ❑1) Once a month 01%) Two times month 02%) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements ❑1) Less than a'' /z hour per day 01%) %z hour a day ❑2) 1 hour a day 02 %) 11/2-2 hours per day 03) 2'A-3 hours per day O 3 Y2) More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week 03%) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑ 1) Face-to-face contact one time Der month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. 02%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑ 0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month 4 ❑1) Less than 4 hours per month 03) 9-12 hours per month Weld County SS -23A Addendt WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a 1 to this child. Aggression/Cruelty to Animals Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions 0 0 Enuresis/Encopresis Runaway Sexual Offenses 0 5 Weld County SS -23A Addends BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensity of conditions which create the need for services that a . • I to this child. O O O O O O O Disruptive Behavior O O O o O O O Delinquent Behavior o O O O O O o Depressive -like Behavior O O O O O O O Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) O O O O O O O Emancipation O O El O O O O Eating Problems O O O O O O O Boundary Issues o O O o o O O Requires Night Care O O O O O O O Education O O O O O O O Involvement with Child's Family O O O O O O O CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 1'/2 ❑ 2 ❑ 2'h ❑ 3 ❑ 3'h 6 Weld County SS -23A Addenda] WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 4.66 Respite Care ($20.39 day/$620 mo) $23.01 4.66 Respite Care ($23.67 day/$720 mo) $26.30 +$.66 Respite Care ($26.96 day/$820 mo) $29.59 +$.66 Respite Care ($30.25 day/$920 mo) $32.88 4.66 Respite Care ($33.54day/$1020 mo) $36.16 +$.66 Respite Care ($36.82 day/$1,120 mo) $39.45 +$.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2 $9.86 day/$300 mo Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2 .. ..$13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2.........$16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts .er week minimum. $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ...$2.99 Level 2..$4.47 Level 3..$6.02 Level 4....Neg. As of 7/01/0E $6.91 day/$210.00 month 7 Weld County SS -23A Addend ,, IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Midi% By: Deputy erk to the Boa Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES Chair Signature CONTRACTOR Imagine 1400 Dixon Ave Lafayette, CO 80026 By: 7e"- 8 a791 Weld County SS -23A Aidders um WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Smith Agency Inc. and Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. rips, The following provisions, made this 1 day of , 2009, are added to the reference>3a6' Agreement. Except as modified hereby, all terms o th Agreement remain unchanged. 1277 4(4 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#44882. 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. County and Contractor agree that for Children's Habilitation Residential Program (CHAP) waiver eligible children, the County agrees to pay the federal SSI rate to Contractor and all other service costs will be billable under the CHRP program. 4. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 5. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 11 t Weld County SS -23A Addend m 9/9: 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. 2 Weld County SS -23A Addendum The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum IDENTIFYING INFORMATION WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE ID# SEX TR [AILS CASE ID IDOB M F I HH# IDATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 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 02%) 5 round trips a week 03) 6 round trips a week P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.) No participation required 02) Three times a month 03%) Three times a week or more ❑1) Once a month 01%) Two times month ❑2%) Once a week 03) Two times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑ Basic Maint.) No educational requirements 01) Less than a''/3 hour per thy 01%) '/x hour a day 02) 1 hour a day 02 %) 11/2-2 hours per day 03) 2'/:-3 hours per day 03%) More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑ Basic Maint.) No special involvement needed 01) Less than 5 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond ase appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ Basic Maint.) 0-2 hours per week ❑1) 3 to 4 hours per week ❑1%z) 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) ['Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) 01) Face-to-face contact one time per month with child and minimal crisis intervention. 01%) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2%) Face-to-face contact three times per month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month 4 ❑1) Less than 4 hours per month 03) 9-12 hours per month Weld County SS -23A Addend, WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a SO 1 to this child. Aggression/Cruelty to Animals Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses 5 Weld County SS -23A Addend BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensit of conditions which create the need for services that a . • I to this child. 0 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation 0 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 ❑ 11/2 ❑ 2 ❑ 2%z ❑ 3 ❑ 3'/ 6 Weld County SS -23A Addend WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint. 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) Admin. Overhead Rate: Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) $19.73 +$.66 Respite Care ($20.39 day/$620 mo) $23.01 +$.66 Respite Care ($23.67 day/$720 mo) $26.30 +$.66 Respite Care ($26.96 day/$820 mo) $29.59 +$.66 Respite Care ($30.25 day/$920 mo) $32.88 +$.66 Respite Care ($33.54day/$1020 mo) $36.16 +$.66 Respite Care ($36.82 day/$1,120 mo) $39.45 +$.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) Basic Maint $4.93 day/$15omo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 1/2 ...... $9.86 day/$300 mo Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month Level 2 1/2 $13.15 day/$400 mo Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 1/2 $16.44 day/$500 mo Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts per week minimum. $13.15 day/$400 mo Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. Level 2 $9.86/$300 mo Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Level 0...$0 (None) Level 1 ...$2.99 Level 2..$4.47 Level 3..$6.02 Level 4....Neg. As of 7/01/0F $6.91 day/$210.00 month 7 Weld County SS -23A Addend IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature CONTRACTOR Smith Agency Inc. 7169 S Liverpool St Centennial, CO 80016 By: £1a.`a.- Ma'' ', M.S. ('a 4- l le0,M Pro c LmA4hiinfrla.o& tamtbir. 8 Weld County SS -23A Add � n�_ WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between WhimSpire CPA and Weld County Department of Human Services for the period from July 1, 2009 through June 30, 2010. Agreement. Except as modified hereby, all terms of heacgreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. The following provisions, made this day of , 2009, are added to the referenced 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#19562. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Section 1, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to provider. 4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person -to -person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or intake screener of any emergency medical, surgical or dental issues prior to granting authorization. During non -regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 304-2749. 7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel available for staffing current placements with the Utilization Review Team. Contractor shall be notified by Department staff of the date and time of the utilization review. 8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. hoar -,?92 Weld County SS -23A Addendum ,9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 8 weeks after placement and forward all appropriate information to the County. 10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities, Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties or their officers or employees may posses, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 2 Weld County SS -23A Addendum .15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Human Services as a debt to Human Services or otherwise as provided by law. 16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 17. Add Section VII - ATTACHMENTS: 3 Weld County SS -23A Addendum WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME WORKER COMPLETING ASSESSMENT STATE ID# HH# SEX !TRAILS CASE ID M F DOB DATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below, please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as outlined in the treatment plan? ❑Basic Maint.) Less than one round trip a week 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 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 031/2) 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? 0 Basic Maint.) No educational requirements ❑1) Less than a''/z hour per day 01%) %z hour a day 02) 1 hour a day 02 %) 1'/:-2 hours per day 03) 2'/2-3 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? ❑ Basic Maint.) No special involvement needed ❑1) Less than 5 hours per week ❑1%z) 5 to 7 hours per week 02) 8 to 10 hours per week 02'A) 11 to 14 hours per week ❑ 3) Constant basis during awake hours 03%) Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond aae appropriate needs with feedin bathing, grooming, physical, and/or occupational therapy? ❑ 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 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3%z) 21 or more hours per week A 1. How often is CPA/County case management required? (Does not include therapy) ❑Basic Maint.) Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1) Face-to-face contact one time per month with child and minimal crisis intervention. 011/2) Face-to-face contact one time per month with child and occasional crisis intervention. 02) Face-to-face contact two times per month with child and occasional crisis intervention. ❑2Yz) Face-to-face contact three timesper month with child and occasional crisis intervention. 03) Face-to-face contact weekly with child and occasional crisis intervention. 03%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group, or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0) Not needed or provided by another source (i.e. Medicaid) 02) 4-8 hours per month 4 01) Less than 4 hours per month 03) 9-12 hours per month Weld County SS -23A Addendu WELD COUNTY DHS NEEDS BASED CARE ASSESSMENT BEHAVIOR ASSESSMENT Please rate the behavior/intensity of conditions which create the need for services that a to this child. Aggression/Cruelty to Animals Verbal or Physical Threatening Destructive of Property/Fire Setting Stealing Self -injurious Behavior Substance Abuse Presence of Psychiatric Symptoms/Conditions Enuresis/Encopresis Runaway Sexual Offenses O 5 Weld County SS -23A Addendu BEHAVIOR ASSESSMENT CONTINUED Inappropriate Sexual Behavior Please rate the behavior/intensit of conditions which create the need for services that ap • I to this child 0 0 0 0 Disruptive Behavior Delinquent Behavior Depressive -like Behavior Medical Needs (If condition is rated "severe", please complete the Medically fragile NBC) Emancipation Eating Problems Boundary Issues Requires Night Care Education Involvement with Child's Family CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ i ❑ 11/2 ❑ 2 ❑ 2'A ❑ 3 ❑ 3'A 6 Weld County SS -23A Addendu WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) County Basic Maint h . Age 0-10...$16.32 ($496) Age 11-14...$18.05 ($549) Age 15-21...$19.27 ($586) + $.66 Respite Care ($20) .. `'". ,, Basic Maint $4.93 day/$150mo No crisis intervention, Minimal CPA involvement, one face-to-face visit with child per month. Level 0 $0 Therapy not needed or provided by another source, i.e. mental health. :_ s 4 1 Level 0...$0 (None) r„ 1 $19.73 +$.66 Respite Care ($20.39 day/$620 mo) '�,„ sr Level 1 $8.22 day/$250 mo Minimal crisis intervention as needed, one face-to-face visit per month with child, 2-3 contacts per month Level 1 $4.93/$150 mo Regularly scheduled therapy, up to 4 hours/month. " Level 1 ...$2.99 1 1/2 $23.01 +$,66 Respite Care ($23.67 day/$720 mo) Level 1 1/2 $9.86 day/$300 mo 2 $26.30 +$.66 Respite Care p'a ($26.96 day/$820 mo) ` ` Level 2 $11.51 day/$350 mo Occasional crisis intervention as needed, two face-to-face visits with child, 2-3 contacts per month x ; Level 2 $9.86/$300 mo. Weekly scheduled therapy, 5-8 hours a month with 4 hours of group therapy. Level 2..$4.47 2 1/2 $29.59 +$,66 Respite Care ($30.25 day/$920 mo) Level 2 1/2 $13.15 day/$400 mo 3 $32.88 4.66 Respite Care ($33.54day/$1020 mo) '-3 Level 3 $14.79 day/$450 mo Ongoing crisis intervention as needed, weekly face-to-face visits with child, and intensive coordination of multiple services. Level 3 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. a Level 3..$6.02 3 1/2 $36.16 +$.66 Respite Care ($36.82 day/$1,120 mo) Level 3 1/2 $16.44 day/$500 mo — 4 RTC Drop Down Assess/ Emergency Level Rate (30 Day Max) a„ -- " ' r!: k t_ $39.45 +$.66 Respite Care ($40.11 day/$1220 mo) $30.25 day/$920 mo (Includes Respite) ' "a Level 4 $18.08 day/$550 mo Ongoing crisis intervention as needed, which includes high level of case management and CPA involvement with child and provider and 2-3 face-to-face contacts .er week minimum. $13.15 day/$400 mo - •.: Level 4 $14.79/$450 mo Regularly scheduled weekly multiple sessions, can include more than 1 person, i.e. family therapy, for 9-12 hours/monthly. Leve14....Neg. .$ Admin. Overhead Rate: $6.91 day/$210.00 month As of 7/01/08 7 Weld County SS -23A Addendu , • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board B Deputy lerk to Approval as to Substance: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: Chair Signature CONTRACTOR WhimSpire CPA 309 S Cascade Ave Montrose, Cp 81401 By: 8 CZ,D9 Y9I Weld County SS -23A Addendum Hello