HomeMy WebLinkAbout20082584.tiff MEMORANDUM
rfta
DATE: September 19, 2008
Vl�Ill
TO: William H. Jerke, Chair, Board of County Commissioners
O FROM: Judy A. Griego, Director, Human Services De rtment
C.
COLORADO RE: Out-of-Home Placemen a en ae el
County Department of H Servi s and V 'ous
Providers for Consent Age a
Enclosed for Board approval are Out-of-Home Placement Agreements between the Weld
County Department of Human Services and various providers. These Agreements can be
placed on the Consent Agenda.
Please see attached Memorandum for the major provisions of these Agreements. The term for
all Agreements is July 1, 2008 through June 30, 2009.
If you have questions please give me a call at extension 6510.
Com.ConsentAgenda.CutofHomeAgreements092408 HA'(2a 79
1
CorlseAtt �F1Lta-
2008-2584
9bit cc eo : Ets oQ -as--0a
RECEIVED AUS 29 2008
Q DEPARTMENT OF HUMAN SERVICES
P.O. BOX A
GREELEY, CO. 80632
i Website: (97 ) el2-1551
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
O
•
COLORADO
MEMORANDUM
TO: Judy Griego — Director
FROM: Lesley Cobb - Child Welfare Rate Negotiator
DATE: August 28, 2008 Al
SUBJECT: Weld Addendum to the Agreements to Purchase Out-of-home Placement
Services (SS-23A)
Attached please find the Weld Addendum to the Agreements to Purchase Out-of-home
Placement Services (SS-23A) for the following providers:
2008-2009 CONTRACTS FOR
CHILD PLACEMENT AGENCY SERVICES
� -srr*53i� exiclisawm,
1 Ariel Child Placement Agency 90205 4251 Kipling St, Unit 500 Wheat Ridge, CO 80033-2899
2 Bridges Inc. 1980 1225 N Main Street, Suite 102 Pueblo, CO 81003
Commonworks D.B.A.
3 Synthesis 104085 3000 Youngfield Street, Suite 155 Lakewood CO 80215
4 Hope & Home 29867 1925 Dominion Way, Ste 200 Colorado Springs, CO 80918
Colorado, Springs CO 80919-
5 REM Colorado, Inc. 37832 4815 List Dr, Suite 111 3340
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 2008-2009. 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 WO County
Department of Human Services for the period from 4/t;
July 1,2008 through June 30, 2009. / P� /2 OQ
The following provisions, made this 3U day of ,A-I l 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the A.*reement 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. 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 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. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum rr
n7�e- &5J
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days 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 W. 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 STATE ID# SEX TRAILS CASE ID IDOB
M F I I
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 ❑1)One round trip a week 01%)2 round trips a week
O2)3-4 round trips a week. O2%) 5 round trips a week O3)6 round trips a week
O3%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required 01)Once a month 01%)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
O3%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular of
special education plan?
❑Basic Maint.)No educational requirements ❑1)Less than a %3 hour per day 01%) %z hour a day
❑2) 1 hour a day O2 %) 1'/-2 hours per day O3)2'/2-3 hours per day
O3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed On Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑3)Constant basis during awake hours O3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin
bathing,grooming,physical,and/or occupational therapy?
❑Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'%) 11 to 15 hours per week ❑3) 16 to 20 per week
O3%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
O2)4-8 hours per month O3)9-12 hours per month
4 Weld County SS-23A Addend,
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that ap.ly to this child.
q7
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ 0 0
Sexual Offenses
❑ ❑ 0 0
5 Weld County SS-23A Addend
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that ap.ly to this child.
d lx 't 4 p fx k#4.''.ts,:.�`..:°......x.�.,:: 6. ti
. t._e..
a.,..,,,r . :4.<.x.k...m i� _... ..k a - e.
Inappropriate Sexual Behavior
❑ 0 0 0
Disruptive Behavior
❑ ❑ 0 0
Delinquent Behavior
❑ ❑ 0 0
Depressive-like Behavior
O 0 0 0
Medical Needs
(If condition is rated"severe",please complete o ❑ 0 0
the Medically fragile NBC)
Emancipation
❑ 0 0 0
Eating Problems
❑ 0 0 0
Boundary Issues
❑ 0 0 0
Requires Night Care
O 0 0 0
Education
❑ ❑ 0 0
Involvement with Child's Family
❑ 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addem
•
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
� � �+. x '' r y„ v a3♦x a t
.17.!:':::::::::°::-::
...4". f .:; .-....:... a . y.....,.....—..„.......,......._..... .:
W ; Age010...$1632
4, ($496) ' Basic Maint $4.93 day/$150mo , Level 0ttt't $0 x
County ,r? Age 11-14...$18 05 t, Therapy not needed or provided .£
Basic ($549) No crisis intervention,Minimal CPA °j by t!.12,.; Level 0...$0
Maint Age 15-21...$19.27 T-I' (None)
Y ($586) involvement,one face-to-face visit SA
another source,i.e.mental health. r+$Ar. .66 Respite Care ai ,
Sys ($20) ,yAvt with child per month. q
61OR Pii
"s $19.73 .'< . Level 1 $8.22 day/$250 mo ' Level 1 $4.93/$150 mo ,`
ittItt
F; +$.66 Respite Care Minimal crisis intervention as needed, t,,= Regularly scheduled therapy, }*tro
_ „- one face-to-face visit per month with s'. t Level 1 ...$2.99
ttltiti ($20.39 day/$620 mo) ` child, .34 up to 4 hours/month. i
4 t 2-3 contacts per month z 1
tittitt $23.01 E. r,
1 1/2 it,3,11 +$.66 Respite Care k=; Level 1 1/2.. ......$9.86 day/$300 mo '`
., ($23.67 day/$720 mo) '' �.. h r
„a
$&+ Ke.°i`. ttl. fie„
,, $26.30 Level 2.......... .....$11.51 day/$350 mo Level 2 $9.86/$300 mo
'6i +$.66 Respite Care x Occasional crisis intervention as needed, !.:ti,,:-...!
am, Weekly scheduled therapy,
2 _ $ r,Niiii a ' Level 2..$4.47
'' ($26.96 day/$820 mo) .3 two face-to-face visits with child, 5-8 hours a month with 4 hours of
•T 'g 2-3 contacts per month group therapy.
°'; $29.59 t t.
2 1/2 $.66 Respite Care h l Level 2 1/2 I.a't, — ,.. _-_-...ift
.
* P $13.15 day/$400 mo
($30.25 day/$920 mo) r n
42 $32.88 RA
Itt Level 3 $14.79 day/$450 mo Level 3.........$14.79/$450 mo
1 4.66 fat tl
Respite Care t: Ongoing crisis intervention as needed g°3` Regularly scheduled weekly k,14t '
3 ;r weekly face-to-face visits Cwith child :41!$..
` multiple sessions,can include
more .,�. Level 3..$6.02
($33.54day/$1020 mo) � and intensive coordination of than 1 person, i.e.family therapy .
till tett multiple services. Eititt for 9-12 hours/monthl
$36.16 pg::a It y i t
viti
Al
3112 '. 4.66 Respite Care ,,; Level 3 1/2 $16.44 day/$500 mo -------- -------- -
1 ($36.82 day/$1,120 mo) .r
74 eel
$39.45 t'',V Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo �,
+$.66 Respite Care St Ongoing crisis intervention as needed Regularly scheduled weekly nt
4 �- t:6 multiple sessions,can include �"%c
RTC x which includes high level of case c more
Drop '}, 1 Leve14....Neg.
Down " ($40.77 day/$1220 mo) .;.,.;;1,31,:. management and CPA involvement with , than 1 person,i.e.family therapy,
child and provider and 2-3 face-to-face :1- for 9-12 hours/monthly. a„
- t
c tip
a ` f;,,: contacts ter week minimum. y
Assess " $26.96 day/$820 mo Lz`t,v`
Rate (Includes Respite) +�",, --------
:tat $11.51 day/$350 mo F
0.4. }+�. u4;.'; .......
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
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: gtakikle4
___
Weld County e VI and
C
4Clam\ WELD COUNTY BOARD OF
\4.-v 1 { HUMAN SERVICES, ON BEHALF
�` OF THE WELD COUNTY
{ ,,,./..
7. /1 DEPARTMENT OF HUMAN
SERVICES
.
By: By:
Deputy rk to the Board Chair Signature
William F. Garcia, Chair Pro-Tem
09/24/2008
CONTRACTOR
Ariel Child Placement Agency
4251 Kipling St, Unit 500
Wheat Ridge, CO,800 003-2899
I
C I J
By:, i' i 1 n ��%(
%' 7)/jd
WELD COUNTY DEPARTMENT 44 'iv.:
OF HUMAN SERVICES Li
By: C a
1p
(41. irector
8 Weld County SS-23A Addendum
axe- a6
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Bridges Inc. and Weld County Department of
Human Services for the period from
July 1, 2008 through June 30,2009.
The following provisions, made this it day of Juut , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the 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#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 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. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum s�
a -a
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
t- 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)
1Ef'TIFYING INFORMATION
HILD'S NAME STATE ID# SEX [TRAILS CASE ID jDOB
M F I I
'ORKER COMPLETING ASSESSMENT HH# !DATE OF ASSESSMENT
GENCY NAME PROVIDER NAME !PROVIDER TRAILS ID
NSWERS 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.
HE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
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 ❑1)One round trip a week 01%)2 round trips a week
02)3-4 round trips a week. 02%) 5 round trips a week ❑3)6 round trips a week
❑3'%x)7 round trips or more
2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required ❑1)Once a month 01%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
03%)Three times a week or more
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'/-3 hours per day
03%)More that 3 hours per day
4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding
bathing,grooming,physical, and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
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
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.
1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑1) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendm
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a,•l to this child.
Aggression/Cruelty to Animals
❑ 0 ❑ ❑
Verbal or Physical Threatening
❑ 0 0 ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ ❑ 0 0
Self-injurious Behavior
❑ 0 0 0
Substance Abuse
❑ 0 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ 0 ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ 0 0 ❑
Sexual Offenses
❑ 0 0 0
5 Weld County SS-23A Addendun
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that a..l to this child.
Inappropriate Sexual Behavior
❑ ❑ 0 0
Disruptive Behavior
❑ ❑ 0 ❑
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
❑ ❑ 0 0
Medical Needs
(If condition is rated"severe",please complete 0 0 0 ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 ❑
Eating Problems
❑ ❑ 0 0
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ 0 0
Education
❑ 0 ❑ 0
Involvement with Child's Family
❑ ❑ 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) n 0 n 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
Age 0-10...$16.32 _ .. .:....
($496) Basic Maint $4.93 day/$150mo < Level 0 $0
County
Age 11-14...$18.05 Therapy not needed or provided
Basic ($549) No crisis intervention,Minimal CPA by Level 0...$0
Maint. Age 15-21...$19.27 (None)
($586) involvement,one face-to-face visit another source,i.e.mental health.
+$.66 Respite Care
($20) with child per month.
$19.73 Level 1 $8.22 day/$250 mo Level 1 $4.93/5150 mo
+$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy,
1 one face-to-face visit per month with Level 1 ...$2.99
($20.39 day/$620 mo) ! child, up to 4 hours/month.
2-3 contacts per month _
$23.01
1 112 +$.66 Respite Care Level 1 1/2.........$9.86 day/$300 mo
($23.67 day/$720 mo)
$26.30 Level 2 $11.51 day/$350 mo Level 2 $9.86/5300 mo
2 +$.66 Respite Care Occasional cnsis intervention as needed, Weekly scheduled therapy, Level 2..$4.47
($26.96 day/$820 mo) two face-to-face visits with child, 5-8 hours a month with 4 hours of
2-3 contacts per month group therapy.
'
$29.59
21/2 -` +$.66 Respite Care Level 2 1/2.. ......$13.15 day/$400 mo ' --
($30.25 day/$920 mo)
$32.88 a r' Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed Regularly scheduled weekly
3 - multiple sessions,can include - Level 3..$6.02
weekly face-to-face visits with child more
($33.54day/$1020 mo) �- and intensive coordination of : than 1 person,i.e.family therapy t
, multiple services. for 9-12 hours/monthly.
$36.16
3 1/2 +5.66 Respite Care ''. Level 3 1/2.........$16.44 day/$500 mo " —
($36.82 day/$1,120 mo)
$39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
+5.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
4 multiple sessions,can include
RTC - which includes high level of case more
Leve14....Neg.
Drop
Down ($40.77 day/$1220 mo) management and CPA involvement with than 1 person,i.e.family therapy,
child and provider and 2-3 face-to-face for 9-12 hours/monthly.
contacts •er week minimum.
Assess $26.96 day/$820 mo '.
Rate (Includes Respite) $11.51 day/$350 mo
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendun
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: gdgliiiirAt
Weld Coun ttphissoard
2 11;. :: )
a WELD COUNTY BOARD OF
f l;'''c. ''__y HUMAN SERVICES, ON BEHALF
., 1( , OF THE WELD COUNTY
G� � ' ✓� DEPARTMENT OF HUMAN
Si' :i t' `,',, .// SERVICES
/
By: /l By:
Deputy C rk to the Board hair Signature
William F. Garcia, Chair Pro-Tem
09/24/2008
CONTRACTOR
Bridges Inc.
1225 N Main Street, Suite 102
Pueblo, CO 81003
B
WELD COUNTY DEPARTMENT //0 Y
OF HUMAN SERVICES
By:
hector
8 Weld County SS-23A Addendum
&ere-ash'
WELD COUNTY ADDENDUM
0
To that certain Agreement to Purchase Child Placement Agency Services r,
(the "Agreement") between Commonworks D.B.A. Synthesis and Weld
County Department of Human Services for the period from s)�
July 1,2008 through June 30, 2009.
The following provisions, made this / day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms f e Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID# 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. 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 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. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days 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 STATE ID# ILEX F TRAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT HH# I IRATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1%)2 round trips a week
O2)3-4 round trips a week. O2%) 5 round trips a week O3)6 round trips a week
O3%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required Dl)Once a month 01%)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
O3%)Three times a week or more
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''/ hour per day 01%) %z hour a day
O2) 1 hour a day O2 %) 1'h-2 hours per day O3)2%r3 hours per day
O3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week O2%) 11 to 14 hours per week
❑3)Constant basis during awake hours O3%)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
O2) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
O3%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
O0)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
O2)4-8 hours per month O3)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DHS
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that ap.l to this child.
}
,e_ .e
Aggression/Cruelty to Animals
❑ ❑ ❑ 0
Verbal or Physical Threatening
❑ ❑ 0 ❑
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ 0 ❑ 0
Self-injurious Behavior
❑ ❑ 0 ❑
Substance Abuse
❑ 0 ❑ 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 0
Enuresis/Encopresis
❑ ❑ 0 0
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
' - (Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that apply to this child.
y
l
Inappropriate Sexual Behavior
❑ 0 0 0
Disruptive Behavior
❑ 0 0 0
Delinquent Behavior
❑ ❑ 0 0
Depressive-like Behavior
❑ ❑ 0 0
Medical Needs
(If condition is rated"severe",please complete O 0 ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 ❑ 0
Eating Problems
❑ 0 0 0
Boundary Issues
❑ 0 0 0
Requires Night Care
❑ 0 0 0
Education
❑ 0 ❑ 0
Involvement with Child's Family
❑ ❑ ❑ ❑
1 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendun
•
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
r Age 0-10...$16.32 :-3i
($496) Basic Maint $4.93 day/$150mo : Level 0 $0 V;
County Age 11-14...$18.05 ''...."n v! Therapy not needed or provided
Basic a ($549) ,:x;, No crisis intervention, Minimal CPA by � Level 0...$0
Age 15-21...$19.27 `:,;: s' +,„ (None)
za ( )
,, ($586) x� involvement,one face-to-face visit :. another source,i.e.mental health.
D +$.66 Respite Care .:,
($20) with child per month.
$19.73 A, Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
1 +$.66 Respite Care Minimal crisis intervention as needed, Regularly scheduled therapy, S
one face-to-face visit per month with i='' Level 1 ...$2.99
($20.39 day/$620 mo) •.3=a" child, :e up to 4 hours/month.
•':4Wrt 2-3 contacts per month t°r"
`` $23.01
1 1/2 _,f +$.66 Respite Care `€4 Level 1 1/2 $9.86 day/$300 mo ,.
--_---
-k ($23.67 day/$720 mo) 'y --------
t„ $26.30 Level 2 $11.51 day/$350 mo a Level 2 $9.86/$300 mo
2 .r +$.66 Respite Care eY Occasional crisis intervention as needed, Weekly scheduled therapy, m'.E Level 2..$4.47
`s two face-to-face visits with child, I 5-8 hours a month with 4 hours of
:,x; ($26.96 day/$820 mo)
' :e ;i 2-3 contacts per month ' " group therapy.
.f.,°- $29.59 4ar,: r+ :' frt
2 1/2 , -4.66 Respite Care `. Level 2 1/2 $13.15 day/$400 mo ta --------- ..3,
($30.25 day/$920 mo) f2 liss
n i
$32.88 i,'.e Level 3 $14.79 day/$450 mo Rv Level 3 $14.79/$450 mo
$'`va +$,66 Respite Care .' Ongoing crisis intervention as needed Regularly scheduled weekly ore
3 :,,,'11 multiple sessions,can include ',V
.. weekly face-to-face visits with child, " more .# Level 3..$6.02
($33.54day/$1020 mo) s' is 14,1
F fps and intensive coordination of x than 1 person,i.e.family therapy,
:x multiple services. for 9-12 hours/monthly. ''
`
'5'v $36.16 i.; w 64
3 1/2 A +$.66 Respite Care ? Level 3 1/2 $16.44 day/$500 mo '
($36.82 day/$1,120 mo) ;;).; ilea rli
$39.45 15
Level 4 $18.08 day/$550 mo } Level 4 $14.79/$450 mo . ',-
-4.66 Respite Care '.s,i. Ongoing crisis intervention as needed, .t Regularly scheduled weekly *-'
4 M '- , multiple sessions,can includey;'
which includes high level of case '-s more
,
Drop 'Al a Level 4....Neg.
Down ' ''e' management and CPA involvement with s than 1 person,i.e.family therapy,
,y� ($40.77 day/$1220 mo) s
Nom' s:.,
)<`"• i-.:' child and provider and 2-3 face-to-face for 9-12 hours/monthly.
contacts 'er week minimum.
Assess Is $26.96 day/$820 mo ('`, }
Rate *.1 (Includes Respite) k.. �d --------
P ) .+,�, $11.51 day/$350 mo -- — .
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
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: M442
Weld CountyClerk tgfthagard
r' ` 7`: ` WELD COUNTY BOARD OF
i t ,4 1-t'—. I HUMAN SERVICES, ON BEHALF
�'' j = ., OF THE WELD COUNTY
%*�3' 1vl DEPARTMENT OF HUMAN
,= \‘'
'rte SERVICES
By: � By: ,
Deputy C rk to the Board Chair Signature
William F. Garcia, Chair Pro-Tem
09/24/2008
CONTRACTOR
Commonworks D.B.A. Synthesis
3000 Youngfield Street, Suite 155
Lakewood CO 80215
nO8 By: .>t.l L .. %CLQ_
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
BY Ot
Irector
8 Weld County SS-23A Addendum
cook- d56`
• WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Hope & Home and Weld County Department m,
Human Services for the period from
July 1, 2008 through June 30, 2009.
The following provisions, made this 1 day of AA , 2008, are added to the referencedC'O
Agreement. Except as modified hereby, all terms thiAgreement 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 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. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
&oo3- Q5
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days 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 STATE ID# ISEX F [TRAILS CASE ID jDOB
WORKER COMPLETING ASSESSMENT HH# 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 01)One round trip a week ❑1%a)2 round trips a week
02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week
03%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required ❑1)Once a month 01%)Two times month
❑2)Three times a month 02%)Once a week
03)Two times a week
03%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1)Less than a%z hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 %) 1%r2 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
❑2)8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedini
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
03%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
❑3)Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
DO)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County SS-23A Addendun
• WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
s... a....a} ... ..3' ,. .t.: .S �,..h,•x.,s:. ..':?t6S. ':•�....z.�wa"��$�u��� '2's% iE,.B rax"a�'t'•S.�..e:t:. . x*_s w t .:x;.a... _,
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ 0
Stealing
❑ ❑ ❑ 0
Self-injurious Behavior
❑ ❑ 0 ❑
Substance Abuse
❑ 0 ❑ 0
Presence of Psychiatric
Symptoms/Conditions 0 ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ 0 0
5 Weld County SS-23A Addendun
•
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that ap.l to this child.
f }
Inappropriate Sexual Behavior
❑ 0 0 ❑
Disruptive Behavior
❑ 0 0 ❑
Delinquent Behavior
❑ 0 ❑ ❑
Depressive-like Behavior
❑ ❑ 0 0
Medical Needs
(If condition is rated"severe",please complete O 0 ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ 0 ❑ ❑
Requires Night Care
❑ 0 0 ❑
Education
❑ 0 ❑ ❑
Involvement with Child's Family
❑ 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendun
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
.
Age 0-10...$16.32 .,s . .:.. ,..,. . . .,.. 3 „ �. ..: ._....,
=:' ($496) Basic Maint $4.93 day/$15omo ' Level 0 $0 v
Count ) Age 11-14...$18.05 z �. ' Therapy not needed or provided _
Basic ($549) ''° : No crisis intervention, Minimal CPA 3*} by s' Level 0...$0
Age 15-21...$19 27 !CU; �..
Maint x ;.. (None)
($586) C: involvement,one face-to-face visit another source,i.e.mental health a
P i'
+$.66 Respite Care . .{
($20) Itr‘r„ with child per month. t°a
$19.73 .:;„:•-,:, Level 1 $8.22 day/$250 mo :: Level 1 $4.93/$150 mo
1 +$.66 Respite Care Minimal crisis intervention as needed :j,':'..:"+ Regularly scheduled therapy
': one face-to-face visit per month with C Level 1 ...$2.99
($20.39 day/$620 mo) child, 1,..-1? up to 4 hours/month.
2-3 contacts per month
-„ $23.01 ''1' r'
1 1/2 +$.66 Respite Care ,f,;- Level 1 1/2.. ......$9.86 day/$300 mo :, '
' ($23.67 day/$720 mo) ..
k $26.30 tic. Level 2 $11.51 day/$350 mo : Level 2 $9.86/$300 mo .-:
ug
2 : +$.66 Respite Care ;#x Occasional crisis intervention as needed, b;: Weekly scheduled therapy, Level 2..$4.47
($26.96 day/$820 mo) 7 i two face-to-face visits with child, • 5-8 hours a month with 4 hours of ,
TM x";
TA 2-3 contacts per month group therapy.
$29.59 _
2 1/2 „ ? 4.66 Respite Care ,p';? Level 2 1/2 ........$13.15 day/$400 mo a ---------------— 4,.
($30.25 day/$920 mo) ? :
gy.
$32.88 ?.a Level 3 $14.79 day/$450 mo +t Level 3 $14.79/$450 mo
k&,
4.66 Respite Care ? Ongoing crisis intervention as needed, ° Regularly scheduled weekly
3 1'' weekly face-to-face visits with child, `ii4 multiple sessmore ons,can incude NA Level 3..$6.02
($33.54day/$1020 mo) x and intensive coordination of r.riil than 1 person,i.e.family therapy, ag
°t multiple services. r for 9-12 hours/monthly.
$36.16 a `4.
31/2 .7. +$.66 Respite Care "" Level 3 1/2.........$16.44 day/$500 mo 'If ------ -------- ---------
($36.82 day/$1,120 mo) m=st p4,
$39.45 -Si. Level 4 $18.08 day/$550 mo . .± Level 4 $14.79/$450 mo
4 +$.66 Respite Care -' Ongoing crisis intervention as needed, Regularly scheduled weekly ,,_
«' i multiple sessions,can include
RTC which includes high level of case more
Drop ry Leve14....Neg.
Down e :, ($40.77 day/$1220 mo) t. $ management and CPA involvement with s.', than 1 person,i.e.family therapy,
5-'f' child and provider and 2-3 face-to-face � '('z. for 9-12 hours/monthly. n.
;;rig` contacts .er week minimum. ,
Assess $26.96 day/$820 mo % t?: a , +
Rate ,q (Includes Respite) " ° — ....
w $11.51 day/$350 mo , .ri
nrs
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
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: a '
Weld Coun t ;,t#jl rd
r �r :.7
d ' WELD COUNTY BOARD OF
r °tea f HUMAN SERVICES, ON BEHALF
\i; ' �,��� OF THE WELD COUNTY
t r� 1-C;(4' ;x,/ DEPARTMENT OF HUMAN
" SERVICES
BY: S.LC 1610A1 By: Lam(/
Deputy erk to the Board Chair Signature
William F. Garcia, Chair Pro-Tem
09/24/2008
CONTRACTOR
Hope & Home
1925 Dominion Way, Ste 200
Colorado Springs, CO 80918
BY: idalZ )S�p0t r
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
hector
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between REM Colorado, Inc. and Weld County
Department of Human Services for the period from
July 1, 2008 through June 30, 2009.
The following provisions, made this ' day of , 2008, 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#37832. 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 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. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
O?66F- a Sc
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days 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 STATE ID# SEX TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# 'DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week 01%)2 round trips a week
02)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week
03%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required 01)Once a month 01%)Two times month
02)Three times a month 02%)Once a week
03)Two times a week
03%)Three times a week or more
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 Yz hour per day 01%) %z hour a day
❑2) 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 ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours 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.)
❑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) ❑1)Less than 4 hours per month
❑2)4-8 hours per month 03)9-12 hours per month
4 Weld County SS-23A Addendun
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which reate the need for services that a..l to this child.
a'L£'a u c�• �„ xrt f�§s `a Ctia'x , t.
i � �£max ti 1 t �E �. � : r a ,
�
�iY`I f '... kn5} i e
.�� ,uea �". � aA%s 4�¢� '�' �_:LB:�....�'ks,;.�'�".n,R.,.t..n� .ua�'h
Aggression/Cruelty to Animals
❑ 0 0 ❑
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ 0 0 0
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ 0 0 0
Presence of Psychiatric
Symptoms/Conditions 0 0 0 0
Enuresis/Encopresis
❑ ❑ 0 ❑
Runaway
❑ 0 ❑ 0
Sexual Offenses
❑ ❑ 0 0
5 Weld County SS-23A Addends
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child.
s4.x.<4'₹. 4. ... ea N.u.i.t r.e....•.'. oaa. .n ...a..i.z o ..m.. n ...__ .. :x .....e... .. i ........ .... .... vva...n r....r....M1
Inappropriate Sexual Behavior
❑ 0 ❑ 0
Disruptive Behavior
❑ 0 0 0
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
❑ 0 0 0
Medical Needs
(If condition is rated"severe",please complete O ❑ 0 0
the Medically fragile NBC)
Emancipation
❑ 0 0 0
Eating Problems
❑ 0 ❑ ❑
Boundary Issues
❑ 0 0 0
Requires Night Care
❑ 0 0 0
Education
❑ ❑ 0 0
Involvement with Child's Family
❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
3 .;5 TY fi . k q
4
', Age 0-10...$16.32 4:
a, ($496) ,';'..r4', Basic Maint $4.93 day/$150mo Level 0 $0 r
County 4 , Age 11-14...$18 05 �?��`, " Therapy not needed or provided (
Basic s� ($549) No crisis intervention, Minimal CPA 0"i by " Level 0...$0
Maint '4` 'I Age 15-21...$19271
}4 r (None)
rc
rir ($586) Cr involvement,one face-to-face visit , another source,i.e.mental health.
k1 +$.66 Respite Care 8,I vv
($20) pot' with child per month. (:,.
$19.73 ,r1, Level l '""f
`a' A $8.22 day/$250 mo .c Level 1..............$4.93/$150 mo
1 :'T r. +$.66 Respite Care + % Minimal crisis intervention as needed, Regularly scheduled therapy, :::',
"'. one face-to-face visit per month with S;'. Level 1 ...$2.99
", ($20.39 day/$620 mo) ' " child, *' up to 4 hours/month. i;:1,1'
;k; 2-3 contacts per month `' s
$23.01 - r 9 '
1 1/2 )°' + .66 Respite Care " ? '�
�' $ P attre Level 1 1/2.. ......$9.86 day/$300 mo r1 ----------- ------ ';';',iii
^ ($23.67 day/$720 mo) \'t s :,.:Y.•
d . $26.30 7.0 Level 2 $11.51 day/$350 mo int Level 2 $9.86/$300 mo i
2 ' +$.66 Respite Care ',A Occasional crisis intervention as needed, ,,' Weekly scheduled therapy, Level 2..$4.47
s fv°
($26.96 day/$820 mo) two face-to-face visits with child k 5-8 hours a month with 4 hours of c>,
a``�F 2-3 contactsper month f
. z t group therapy. a {
� $29.59 .�°ky s i ?
2 1/2 Z 4.66 Respite Care Level 2 1/2.........$13.15 day/$400 mo ar Al..‘,
a'`'1 ($30.25 day/$920 mo) i. t`.3 �kk
$32.88 Level 3 li
$14.79 day/$450 mo t Level 3 $14.79/$450 mo
ay$ 4.66 Respite Care , s Ongoing crisis intervention as needed, Regularly scheduled weekly
3 6. multiple sessions,can include t,
', weekly face-to-face visits with child, more Iht " Level 3..$6.02
($33.54day/$1020 mo) `E }.
and intensive coordination of t: than 1 person,i.e.family therapy, i'''
a
multiple services. i'4 for 9-12 hours/monthly. y
$36.16 '^`
,
3 1/2 ' +$.66 Respite Care Level 3 1/2 ........$16.44 day/$500 mo 2 �'
($36.82 day/$1,120 mo) . ---------
41 KIE
$39.45 Level 4 $18.08 day/$550 mo , ' Level 4 $14.79/$450 mo ;
4 A 4.66 Respite Care „t Ongoing crisis intervention as needed, Regularly scheduled weekly ,.
pp multiple sessions,can include
RTC sv i �" which includes high level of case , more t
Drop r Leve14....Neg.
Down ' ($40.77 day/$1220 mo) management and CPA involvement with ' ' . than 1 person, i.e.family therapy,
a
r s child and provider and 2-3 face-to-face i1 for 9-12 hours/monthly.tt
ficy
2 :: i..;, contacts .er week minimum. _• >'
.. Ferri.
Assess $26.96 day/$820 mo �a b'''
14
Rate U (Includes Respite) S'' $11.51 day/$350 mo to .
fg
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendur
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: get/4W
Weld County Cl Vi;
L
4J x' WELD COUNTY BOARD OF
t(%6A �';, ' _t HUMAN SERVICES, ON BEHALF
Y r OF THE WELD COUNTY
DEPARTMENT OF HUMAN
'"7- - )1 SERVICES
By: By:
Deputy Cl to the Board Chair Signature
� Y
William F. Garcia, Chair Pro-Tem
09/24/2008
CONTRACTOR
REM Colorado, Inc.
4815 List Dr, Suite 111
Colorado, Springs CO 80919-3340
BY:J4,,^ Y-
, n,
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
rector
8 Weld County SS-23A Addendum
c op- as a
Hello